assessment

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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 psychiatrist but continued to deny self-injection.

The next day, the patient tearfully confessed that she had had bacteriological materials in her purse,

but she said she used them only to aspirate and culture some blisters on her skin. She still denied self-

injection with bacteria and said she wanted the doctors to “keep looking for the cause of my problems.”

(Savino & Fordtran, 2006, pp. 201–202)

TABLE: 9-1

Checklist

Factitious Disorder Imposed on Self

1. False creation of physical psychological symptoms, or deceptive production of injury or disease, even without external rewards for such ailments.

2. Presentation of oneself as ill, damaged, or hurt.

Factitious Disorder Imposed on Another

1. False creation of physical or psychological symptoms, or deceptive production of injury or disease, in another person, even without external rewards for such ailments.

2. Presentation of another person (victim) as ill, damaged, or hurt.

Information from: APA, 2022.

Factitious disorder is known popularly as Munchausen syndrome, a label derived from the exploits of Baron von Münchhausen, an eighteenth-century cavalry officer who journeyed from tavern to tavern in Europe telling fantastical tales about his supposed military adventures (Prabhu et al., 2020). People with factitious disorder often go to extremes to create the appearance of illness (APA,

2022). Many give themselves medications secretly. Some, like the woman just

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described, inject drugs to cause bleeding, infections, or other problems. Still others use laxatives to produce chronic diarrhea (Wald, 2019). High fevers are especially easy to create. In studies of patients with a prolonged mysterious fever, 9 percent were eventually diagnosed with factitious disorder (Irwin &

Bursch, 2019).

of NOTE … Time of Assessment

22% Percentage of family physician patient visits lasting 10 minutes

29% Percentage of family physician patient visits lasting 14 minutes

33% Percentage of family physician patient visits lasting 20 minutes

(Information from: Statista, 2019c.)

People with factitious disorder often research their supposed ailments and are impressively knowledgeable about medicine. Many eagerly undergo painful testing or treatment, even surgery. When confronted with evidence that their symptoms are factitious, they typically deny the charges and leave the hospital; they may enter another hospital the same day.

Clinical researchers have had a hard time determining the prevalence of factitious disorder, since patients with the disorder hide the true nature of their problem (Chafetz et al., 2020). Overall, the pattern appears to be more common in women than men. Men, however, may more often have severe cases. The disorder usually begins during early adulthood.

Factitious disorder seems to be particularly common among people who (1) received extensive treatment for a medical problem as children, (2) carry a grudge against the medical profession, or (3) have worked as a nurse, laboratory technician, or medical aide (Jimenez et al., 2020; Yates & Feldman, 2017). A

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number have poor social support, few enduring social relationships, and little family life (Irwin & Bursch, 2019).

The precise causes of factitious disorder are not understood, although clinical reports have pointed to factors such as depression, unsupportive parental relationships during childhood, and extreme needs for attention and/or social support that are not otherwise available (Jimenez et al., 2020; Irwin & Bursch, 2019). Nor have clinicians been able to develop dependably effective treatments for this disorder.

Psychotherapists and medical practitioners often report feelings of annoyance or anger toward people with factitious disorder, feeling that these people are, at the very least, wasting their time. Yet people with the disorder feel they have no control over the problem, and they often experience great distress.

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, leading in some cases to repeated painful diagnostic tests, medication, and surgery (Ban & Shaw, 2019) (see Table 9-1 again). If the children are removed from their parents and placed in the care of

others, their symptoms disappear (see PsychWatch).

PSYCHWATCH Munchausen Syndrome by Proxy

Tanya, a mere 8 years old, had been hospitalized 127 times over the past 5 years and undergone

28 different medical procedures — from removal of her spleen to exploratory surgery of her intestines.

Two months ago, her mother was arrested, charged with child endangerment. When Tanya’s

grandmother gently tried to talk to the girl about her mother’s arrest (or, as she put it, “Mommy’s going

away”), Tanya was upset and confused.

“I miss Mommy so much. She’s the best person in the world. She spent all her time with me in the

hospital. They say Mommy was making me feel bad, putting bad stuff in my tube. But there’s no way

Mommy made me feel that bad.”

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Cases like Tanya’s have horrified the public and called attention to Munchausen syndrome by proxy.

This form of factitious disorder is caused by a caregiver who uses various techniques to induce

symptoms in a child — giving the child drugs, tampering with medications, contaminating a feeding

tube, or even smothering the child, for example (Hoffman & Koocher, 2019; Roesler & Jenny, 2018).

The illness can take almost any form, but the most common symptoms are bleeding, seizures,

asthma, comas, diarrhea, vomiting, “accidental” poisonings, infections, fevers, and sudden infant

death syndrome (Kugler, 2019).

Between 6 and 10 percent of the victims of Munchausen syndrome by proxy die as a result of their

symptoms, and some of those who survive are permanently disfigured or physically impaired

(Kugler, 2019; Braham et al., 2017). Psychological, educational, and physical development are also

affected (Ban & Shaw, 2019).

Convalescent, 1867, by Frank Holl

The syndrome is very hard to diagnose and may be more common than clinicians once thought

(Hoffman & Koocher, 2019). The parent (usually the mother) comes across as deeply devoted and

caring, thus eliciting sympathy and admiration from others. Yet the physical problems disappear

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when the child and parent are separated. In many cases, siblings of the sick child are also victimized

(Braham et al., 2017).

Should society treat or punish those parents who produce Munchausen syndrome by proxy in their children?

What kind of parent carefully inflicts pain and illness on a child? The typical Munchausen parent is

emotionally needy and craves the attention and praise they receive for their devoted care of the sick

child (Sanders & Bursch, 2020; Anderson, Feldman, & Bryce, 2018). The parent may have little social

support outside the medical system. O�en the caregivers have a medical background of some kind.

A number have medically unexplained physical problems of their own (Roesler & Jenny, 2018).

Typically, they deny their actions, even in the face of clear evidence, and initially may refuse to

undergo therapy.

Law enforcement authorities approach Munchausen syndrome by proxy as a crime — a carefully

planned form of child abuse (Kugler, 2019). They typically require that the child be separated from

the parent, at least for a period of time. At the same time, a parent who resorts to such actions is

seriously disturbed and greatly in need of clinical help (Sanders & Bursch, 2020). In many cases,

particularly those that are of moderate or modest severity, treatment makes it possible for the

parent to be reintegrated into the family (Roesler & Jenny, 2018). Currently, clinical researchers and

practitioners are working to develop still clearer insights and more effective treatments for such

parents and their young victims.

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Conversion Disorder and Somatic Symptom Disorder

WHEN A BODILY AILMENT has an excessive and disproportionate impact on the person, has no apparent medical cause, or is inconsistent with known medical diseases, physicians may suspect a conversion disorder or a somatic symptom disorder. Consider the plight of Brian:

Brian was spending Saturday sailing with his wife, Helen. The water was rough but well within what

they considered safe limits. They were having a wonderful time and really didn’t notice that the sky was

getting darker, the wind blowing harder, and the sailboat becoming more difficult to control. A�er a few

hours of sailing, they found themselves far from shore in the middle of a powerful and dangerous storm.

The storm intensified very quickly. Brian had trouble controlling the sailboat amidst the high winds and

wild waves. He and Helen tried to put on the safety jackets they had neglected to wear earlier, but the

boat turned over before they were finished. Brian, the better swimmer of the two, was able to swim

back to the overturned sailboat, grab the side, and hold on for dear life, but Helen simply could not

overcome the rough waves and reach the boat. As Brian watched in horror and disbelief, his wife

disappeared from view.

A�er a time, the storm began to lose its strength. Brian managed to right the sailboat and sail back to

shore. Finally he reached safety, but the personal consequences of this storm were just beginning. The

next days were filled with pain and further horror: the Coast Guard finding Helen’s body … texts, e-

mails, and conversations with family members and friends … self-blame … grief … and more.

Compounding this horror, the accident had le� Brian with a severe physical impairment — he could not

walk properly. He first noticed this terrible impairment when he sailed the boat back to shore, right

a�er the accident. As he tried to run from the sailboat to get help, he could hardly make his legs work.

By the time he reached the nearby beach restaurant, all he could do was crawl. Two patrons had to li�

him to a chair, and a�er he told his story and the authorities were alerted, he had to be taken to a

hospital.

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At first Brian and the hospital physician assumed that he must have been hurt during the accident. One

by one, however, the hospital tests revealed nothing — no broken bones, no spinal damage, nothing.

Nothing that could explain such severe impairment.

By the following morning, the weakness in his legs had become near paralysis. Because the physicians

could not pin down the nature of his injuries, they decided to keep his activities to a minimum. He was

not allowed to talk long with the police. To his deep regret, he was not even permitted to attend Helen’s

funeral.

The mystery deepened over the following days and weeks. As Brian’s paralysis continued, he became

more and more withdrawn, unable to see more than a few friends and family members and unable to

take care of the many unpleasant tasks attached to Helen’s death. He could not bring himself to return

to work or get on with his life. Texting, e-mailing, and phone conversations slowly came to a halt. At

most, he was able to go online and surf the Internet. Almost from the beginning, Brian’s paralysis had

le� him self-absorbed and drained of emotion, unable to look back and unable to move forward.

of NOTE … Seeking Relief

Research suggests that 17 percent of patients under the care of family physicians display physical

symptoms that have no apparent physical cause (Greenberg, 2016).

Conversion Disorder Eventually, Brian received a diagnosis of conversion disorder, increasingly referred to in clinical circles and in DSM-5-TR as functional neurological symptom disorder (see Table 9-2). People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases (APA, 2022). In short, they have neurological-like symptoms — for example, paralysis, blindness, or loss of feeling — that have no neurological basis.

TABLE: 9-2

Checklist

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Conversion Disorder (Functional Neurological Symptom Disorder)

1. Presence of at least one symptom or deficit that affects voluntary or sensory function.

2. Symptoms are found to be inconsistent with known neurological or medical disease.

3. Significant distress or impairment.

Information from: APA, 2022.

Conversion disorder often is hard, even for physicians, to distinguish from a

genuine medical problem (Bransfield & Friedman, 2019). In fact, it is always possible that a diagnosis of conversion disorder is a mistake and that the patient’s problem has an undetected neurological or other medical cause (Stone & Sharpe, 2020a, 2019). Because conversion disorders are so similar to “genuine” medical ailments, physicians sometimes rely on oddities in the patient’s medical picture to help distinguish the two. The symptoms of a conversion disorder may, for example, be at odds with the way the nervous system is known to work. In a conversion symptom called glove anesthesia, numbness begins sharply at the wrist and extends evenly right to the fingertips. As Figure 9-1 shows, real neurological damage is rarely as abrupt or evenly spread out.

FIGURE 9-1

Glove Anesthesia

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In this conversion symptom (le� figure) the entire hand, extending from the fingertips to the wrist, becomes numb. Actual physical damage (right figure) to the

ulnar nerve, in contrast, causes anesthesia in the ring finger and little finger and beyond the wrist partway up the arm; damage to the radial nerve causes loss of

feeling only in parts of the ring, middle, and index fingers and the thumb and partway up the arm. (Information from: Gray, 1959.)

The physical effects of a conversion disorder may also differ from those of the corresponding medical problem (Stone & Sharpe, 2020a). For example, when

paralysis from the waist down, or paraplegia, is caused by damage to the spinal cord, a person’s leg muscles may atrophy, or waste away, unless physical therapy is applied. The muscles of people whose paralysis is the result of a conversion disorder, in contrast, do not usually atrophy. Perhaps those with a conversion disorder exercise their muscles without being aware that they are doing so. Similarly, people with conversion blindness have fewer accidents than people who are organically blind, an indication that they have at least some vision even if they are unaware of it.

Unlike people with factitious disorder, those with conversion disorder do not consciously want or purposely produce their symptoms. Like Brian, they almost always believe that their problems are genuinely medical. This pattern is called “conversion” disorder because clinical theorists used to believe that individuals

with the disorder are converting psychological needs or conflicts into their neurological-like symptoms (Cretton et al., 2020). Although some theorists still believe that conversion is at work in the disorder, others prefer alternative kinds of explanations, as you’ll see later.

Conversion disorder usually begins between late childhood and young adulthood; it is diagnosed at least twice as often in women as in men (de Vroege et al., 2020). It often appears suddenly, at times of extreme stress (Stone & Sharpe, 2020b). In some, but far from all, cases, conversion disorder lasts a matter of weeks. Some research suggests that people who develop the disorder tend to be generally suggestible (see MindTech). Many are highly susceptible to hypnotic procedures, for example (Williamson, 2019; Tsui et al., 2017). It is

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thought to be a rare problem, occurring in 1 to 5 of every 500 persons (de Vroege et al., 2020; Stone & Sharpe, 2019).

MINDTECH Can Social Media Spread “Mass Hysteria”?

In Chapter 1, you read about outbreaks during the Middle Ages of mass hysteria, also called mass

madness or mass psychogenic illness, in which large numbers of people would share psychological or

physical maladies that had no medical cause (see page 9). In 2020, during the earliest stages of the

COVID-19 pandemic, some observers applied this term incorrectly to the many people worldwide

who feared they might contract the virus, isolated themselves, and wore gloves and masks outside

of the house (Gowen, 2020). But those individuals were not displaying mass hysteria — they were

simply early assessors of an all-too-real medical problem that ultimately required extraordinary

measures by everyone.

On the other hand, instances of mass hysteria do o�en occur in today’s world. In a common

occurrence, for example, large numbers of frenzied fans at music concerts collectively display

extreme emotionality and lack of restraint during performances by their musical idols, accompanied

in many cases by physical symptoms such as fainting, tremors, and even convulsions. Similarly, our

world periodically witnesses outbreaks of mysterious illnesses that have no medical cause. In fact,

the number of such cases may be on the increase (Nelson, 2019; Ayehu et al., 2018). Most of today’s

clinicians consider such outbreaks of mass hysteria a form of conversion disorder.

New Zealand sociologist Robert Bartholomew (2018, 2014) has been studying mass psychogenic

illnesses that date back over 400 years, and he argues that social media is a major factor in the

current increase. One notable outbreak in Le Roy, New York, demonstrates the suggestive role

played by social media (Nelson, 2019). Back in 2011, a local high school student began having facial

spasms. A�er several weeks, others started having similar symptoms, and eventually 18 girls from

the high school were affected. Apparently, a number of these teenagers began to show symptoms

a�er they saw a YouTube video featuring a girl from a nearby town who had significant tics. Doctors

eventually concluded that this was an example of mass psychogenic illness.

An unusual aspect of the Le Roy case that further points to the likely role of social media is that in

addition to the 18 high school girls, a 36-year-old woman with no connection to the teenage girls

also began having the same symptoms during the same period of time. She stated that she first saw

the facts of the case on a Facebook post.

This case mirrors others in more recent years (Ayehu et al., 2018; Bartholomew & Pérez, 2018),

including an outbreak of hiccups and vocal tics among teenagers in Danvers, Massachusetts, and the

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case of 400 garment workers in a Bangladesh factory who had severe gastrointestinal symptoms for

which there was ultimately no physical explanation. In these and other cases, the symptoms seemed

to be spread, at least in part, by social media exposure.

Bartholomew (2018, 2014) believes that due to the power of social media, future outbreaks of mass

hysteria may be more numerous, wide ranging, and severe than any yet recorded. He observes that

in the distant past “the local priests, who were … summoned to [treat mass psychogenic illnesses],

faced a daunting task … but they were fortunate in one regard: they did not have to contend with

mobile phones, Twitter, and Facebook.”

Modern mass hysteria? These frenzied fans display extreme emotionality and lack of restraint at the

midnight launch of a Harry Potter book, a group pattern that o�en earns a label of mass hysteria.

Somatic Symptom Disorder People with somatic symptom disorder become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing, and their lives are greatly disrupted by those symptoms (APA, 2022) (see Table 9-3).

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The symptoms last longer but are less dramatic than those found in conversion disorder. In some cases, the somatic symptoms have no known cause; in others, the cause can be identified. Either way, the person’s concerns are disproportionate to the seriousness of the bodily problems.

TABLE: 9-3

Checklist

Somatic Symptom Disorder

1. Person experiences at least one upsetting or repeatedly disruptive physical (somatic) symptom.

2. Person experiences an unreasonable number of thoughts, feelings, and behavior regarding the nature or implications of the physical symptoms, including one of the following: a. Repeated, excessive thoughts about their seriousness. b. Continual high anxiety about their nature or health implications. c. Disproportionate amounts of time and energy spent on the symptoms or their health implications.

3. Physical symptoms usually continue to some degree for more than 6 months.

Information from: APA, 2022.

Two patterns of somatic symptom disorder have received particular attention. In one, sometimes called a somatization pattern, the individual experiences a large and varied number of bodily symptoms. In the other, called a predominant pain pattern, the person’s primary bodily problem is the experience of pain.

Somatization Pattern

Sheila baffled medical specialists with the wide range of her symptoms:

Sheila reported having abdominal pain since age 17, necessitating exploratory surgery that yielded

no specific diagnosis. She had several pregnancies, each with severe nausea, vomiting, and abdominal

pain; she ultimately had a hysterectomy for a “tipped uterus.” Since age 40 she had experienced

dizziness and “blackouts,” which she eventually was told might be multiple sclerosis or a brain tumor.

She continued to be bedridden for extended periods of time, with weakness, blurred vision, and

difficulty urinating. At age 43 she was worked up for a hiatal hernia because of complaints of bloating

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and intolerance of a variety of foods. She also had additional hospitalizations for neurological,

hypertensive, and renal workups, all of which failed to reveal a definitive diagnosis.

(Spitzer et al., 1994, 1981, pp. 185, 260)

Like Sheila, people with a somatization pattern of somatic symptom disorder experience many long-lasting physical ailments — ailments that typically have little or no physical basis. This pattern, first described by Pierre Briquet in 1859, is also known as Briquet’s syndrome. A sufferer’s ailments often include pain symptoms (such as headaches or chest pain), gastrointestinal symptoms (such

as nausea or diarrhea), sexual symptoms (such as erectile or menstrual difficulties), and neurological-type symptoms (such as double vision or paralysis).

People with a somatization pattern usually go from doctor to doctor in search of relief. They often describe their many symptoms in dramatic and exaggerated

terms. Most also feel anxious and depressed (Cao et al., 2020; Levenson, 2020a). The pattern typically lasts for many years, fluctuating over time but rarely disappearing completely without therapy.

Mind over matter The opposite of conversion and somatic symptom disorders —

although again demonstrating the power of psychological processes — are instances

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in which people “ignore” pain or other physical symptoms. Here a London performance artist smiles while her skin is being pierced with sharp hooks that help

suspend her from the ceiling above. Her action was part of a protest to end shark finning — the practice of cutting off a shark’s fin and throwing its still-living body

back into the sea so that the fins can be used in the production of shark fin soup (a food delicacy) and other goods.

Around 4 percent of all people in the United States may experience a somatization pattern in any given year, women much more commonly than men

(Levenson, 2020a). The pattern often runs in families; as many as 20 percent of the close female relatives of women with the pattern also develop it. It usually begins between adolescence and young adulthood.

Predominant Pain Pattern

If the primary feature of somatic symptom disorder is pain, the person is said to have a predominant pain pattern. Patients with conversion disorder or another pattern of somatic symptom disorder may also experience pain, but it is the key

symptom in this pattern. The source of the pain may be known or unknown. Either way, the concerns and disruption produced by the pain are disproportionate to its severity and seriousness.

of NOTE … Common Pain

80% Percentage of U.S. population that experience back pain sometime in their lives

29% Percentage of U.S. population currently experiencing lower back pain

(Information from: PPM, 2020.)

Although the precise prevalence has not been determined, this pattern appears to be fairly common (Levenson, 2020a). It may begin at any age, and women seem more likely than men to experience it. Often it develops after an accident

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or during an illness that has caused genuine pain, after which the pain takes on a life of its own. For example, Laura, a 36-year-old woman, reported pains that went far beyond the usual symptoms of her tubercular disease called sarcoidosis:

Before the operation I would have little joint pains, nothing that really bothered me that much. A�er

the operation I was having severe pains in my chest and in my ribs, and those were the type of problems

I’d been having a�er the operation, that I didn’t have before…. I’d go to an emergency room at night,

11:00, 12:00, 1:00 or so. I’d take the medicine, and the next day it stopped hurting, and I’d go back

again. In the meantime this is when I went to the other doctors, to complain about the same thing, to

find out what was wrong; and they could never find out what was wrong with me either….

At certain points when I go out or my husband and I go out, we have to leave early because I start

hurting…. A lot of times I just won’t do things because my chest is hurting for one reason or another….

Two months ago when the doctor checked me and another doctor looked at the x-rays, he said he didn’t

see any signs of the sarcoid then and that they were doing a study now, on blood and various things, to

see if it was connected to sarcoid….

(Green, 1985, pp. 60–63)

What Causes Conversion and Somatic Symptom Disorders? For many years, conversion and somatic symptom disorders were referred to as hysterical disorders. This label was meant to convey the prevailing belief that excessive and uncontrolled emotions underlie the bodily symptoms found in these disorders.

Work by Ambroise-Auguste Liébault and Hippolyte Bernheim in the late nineteenth century helped foster the notion that such psychological factors were at the root of hysterical disorders. These researchers founded the Nancy School in Paris for the study and treatment of mental disorders. There they were

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able to produce hysterical symptoms in normal people — deafness, paralysis, blindness, and numbness — by hypnotic suggestion, and they could remove the symptoms by the same means (see Chapter 1). If hypnotic suggestion could both produce and reverse physical dysfunctions, they concluded, hysterical disorders

might themselves be caused by psychological processes.

Why do the terms “hysteria” and “hysterical” currently have such negative connotations in our society, as in “mass hysteria” and “hysterical personality”?

Today’s leading explanations for conversion and somatic symptom disorders come from the psychodynamic, cognitive-behavioral, and multicultural models. None has received much research support, however, and the disorders are still poorly understood (Levenson, 2020a; Stone & Sharpe, 2019).

The Psychodynamic View

As you read in Chapter 1, Freud’s theory of psychoanalysis began with his efforts to explain hysterical symptoms. Indeed, he was one of the few clinicians of his day to treat patients with these symptoms seriously, as people with genuine problems. After studying hypnosis in Paris, Freud became interested in the work of an older physician, Josef Breuer (1842–1925). Breuer had successfully used hypnosis to treat a woman he called Anna O., who suffered from hysterical

deafness, disorganized speech, and paralysis (Ellenberger, 1972). On the basis of this and similar cases, Freud (1894/1962) came to believe that hysterical disorders represented a conversion of underlying emotional conflicts into physical symptoms and concerns (Ding & Kanaan, 2017).

of NOTE … Diagnostic Controversy

Even people whose physical symptoms are caused by significant medical problems may qualify for a

DSM-5-TR diagnosis of somatic symptom disorder if they are overly anxious or upset by their medical

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problems. Critics worry that many patients who are understandably upset by having cancer, heart

disease, or other serious diseases may incorrectly receive a diagnosis of somatic symptom disorder.

Observing that most of his patients with hysterical disorders were women, Freud centered his explanation of such disorders on the needs of girls during their

phallic stage (ages 3 through 5). At that time in life, he believed, all girls develop a pattern of desires called the Electra complex: each girl experiences sexual feelings for her father and at the same time recognizes that she must compete with her mother for his affection. However, aware of her mother’s more powerful position and of cultural taboos, the child typically represses her sexual feelings and rejects these early desires for her father.

Freud believed that if a child’s parents overreact to her sexual feelings — with strong punishments, for example — the Electra conflict will be unresolved and the child may reexperience sexual anxiety throughout her life. Whenever events trigger sexual feelings, she may feel an unconscious need to hide them from both herself and others. Freud concluded that some women hide their sexual feelings by unconsciously converting them into physical symptoms and

concerns.

Most of today’s psychodynamic theorists take issue with parts of Freud’s explanation of conversion and somatic symptom disorders, but they continue to believe that sufferers of the disorders have unconscious conflicts carried forth from childhood that arouse anxiety, and that they convert this anxiety into

“more tolerable” physical symptoms (Cretton et al., 2020; Levenson, 2020a; Stone & Sharpe, 2019).

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Electra complex goes awry Freud argued that a hysterical disorder may result when parents overreact to their daughter’s early displays of affection for her father, by

repeatedly punishing her, for example. The child may go on to exhibit sexual repression in adulthood and convert sexual feelings into physical ailments.

Psychodynamic theorists propose that two mechanisms are at work in these disorders — primary gain and secondary gain. People derive primary gain when their bodily symptoms keep their internal conflicts out of awareness. During an argument, for example, a man who has underlying fears about expressing anger

may develop a conversion paralysis of the arm, thus preventing his feelings of rage from reaching consciousness. People derive secondary gain when their bodily symptoms further enable them to avoid unpleasant activities or to receive sympathy from others. When, for example, a conversion paralysis allows a soldier to avoid combat duty or conversion blindness prevents the breakup of a relationship, secondary gain may be at work. Similarly, the conversion paralysis of Brian, the man who lost his wife in the boating accident, seemed to help him avoid many painful duties after the accident, such as attending her funeral and

returning to work.

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The Cognitive-Behavioral View

Cognitive-behavioral theorists point to somatic vigilance, rewards, and communication skills to help explain conversion and somatic symptom disorders.

In the realm of somatic vigilance, they suggest that some people are more attentive than others to their bodies, and this attentiveness causes them to focus more on their bodily discomforts, experience more arousal in response to them, and worry about them more. This notion is similar to that of anxiety sensitivity, the personal inclination to focus on bodily sensations that is linked to panic disorder (see page 137). Consistent with the somatic vigilance explanation of conversion and somatic symptom disorders, researchers have found that people with higher levels of such vigilance experience pain and pain-related

anxiety more often than people with lower levels (Burton et al., 2020; Zvolensky et al., 2019).

In the realm of rewards, cognitive-behavioral theorists propose that the physical symptoms of these disorders yield important benefits to sufferers (see Table 9- 4). Perhaps the symptoms remove the individuals from an unpleasant relationship or perhaps the symptoms bring attention from other people (Levenson, 2020a; Witthöft et al., 2018). In response to such rewards, the sufferers learn to display the bodily symptoms more and more prominently. The theorists also hold that people who are familiar with an illness will more readily adopt its physical symptoms. In fact, studies find that many sufferers develop their bodily symptoms after they or their close relatives or friends have had similar medical problems (Stone & Sharpe, 2020a, 2020b).

TABLE: 9-4

Disorders That Have Somatic Symptoms

Disorder Voluntary Control of Symptoms?

Symptoms Linked to Psychosocial Factor?

An Apparent Goal?

Malingering Yes Maybe Yes

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Factitious disorder Yes Yes No

Conversion disorder No Yes Maybe

Somatic symptom disorders

No Yes Maybe

Illness anxiety disorder No Yes No

Psychophysiological disorder

No Yes No

Physical illness No Maybe No

Except for medical attention.

of NOTE … Diagnostic Confusion

In the past, whiplash was regularly misdiagnosed as a psychologically caused condition.

Clearly, this focus on the role of rewards is similar to the psychodynamic notion of secondary gain. The key difference is that psychodynamic theorists view the gains as indeed secondary — that is, as gains that come only after underlying conflicts produce the disorders. Cognitive-behavioral theorists view them as the primary cause of the development of the disorders.

i

i

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Can pain be learned? This baby is about to be given a vaccination. How much pain will she feel? According to research, it depends in large part on her mother. Infants of

first-time mothers express significantly more pain before and during vaccine injections than do infants of experienced mothers. Apparently, through facial

gestures, body language, modeling, or other conditioning processes, new mothers actually help produce more pain in their children.

Like the psychodynamic explanation, the reward explanation of conversion and somatic symptom disorders has received little research support. Even clinical case reports only occasionally support this position. In many cases, the pain and upset that surround the disorders seem to outweigh any rewards the symptoms

might bring.

In the communication realm, some cognitive-behavioral theorists propose that conversion and somatic symptom disorders are forms of self-expression, providing a means for people to reveal emotions that would otherwise be

difficult for them to convey (Levenson, 2020a). Like their psychodynamic colleagues, these theorists hold that the emotions of people with the disorders are being converted into physical symptoms. They suggest, however, that the purpose of the conversion is not to defend against anxiety but to communicate extreme feelings — anger, fear, depression, guilt, jealousy — in a “physical language” that is familiar and comfortable for the person with the disorder.

According to this view, people who find it particularly hard to recognize or express their emotions are candidates for conversion and somatic symptom disorders (Levenson, 2020a; Erkic et al., 2018). So are those who “know” the language of physical symptoms through firsthand experience with a genuine physical ailment. Because children are less able to express their emotions verbally, they are particularly likely to develop physical symptoms as a form of

communication (Burton et al., 2020). Like the other explanations, this cognitive- behavioral view has not been widely tested or supported by research (Stone & Sharpe, 2019).

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The Multicultural View

Most Western clinicians believe that it is inappropriate to produce or focus excessively on somatic symptoms in response to personal distress. That is, in part, why conversion and somatic symptom disorders are included in DSM-5-TR. Some theorists believe, however, that this position reflects a Western bias — a bias that sees somatic reactions as an inferior way of dealing with emotions (Canna & Seligman, 2020; Krupić et al., 2019).

In fact, the transformation of personal distress into somatic complaints is the norm in many non-Western cultures (Levenson, 2020a). In such cultures, the formation of such complaints is viewed as a socially and medically correct — and less stigmatizing — reaction to life’s stressors. Studies have found very high rates of stress-caused bodily symptoms in non-Western medical settings

throughout the world, including those in China, Japan, and Arab countries (Löwe & Gerloff, 2018; Matsumoto & Juang, 2016). People throughout Latin America seem to display the most somatic reactions. Even within the United States, Hispanic Americans display more somatic reactions in the face of stress than do other populations (Zvolensky et al., 2019; Calzada et al., 2017).

The lesson to be learned from such multicultural findings is not that somatic reactions to stress are superior to psychological ones or vice versa, but rather, once again, that both bodily and psychological reactions to life events are often influenced by one’s culture. Overlooking this point can lead to knee-jerk mislabels or misdiagnoses.

How Are Conversion and Somatic Symptom Disorders Treated? People with conversion and somatic symptom disorders usually seek psychotherapy only as a last resort (Levenson, 2020b). They believe that their problems are completely medical and at first reject all suggestions to the contrary. When a physician tells them that their symptoms or concerns have a

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psychological dimension, they often go to another physician. Eventually, however, many patients with these disorders do consent to psychotherapy, psychotropic drug therapy, or both.

Many therapists focus on the causes of these disorders (the trauma or anxiety tied to the physical symptoms) and apply insight, exposure, and drug therapies. Psychodynamic therapists, for example, try to help those with somatic

symptoms become conscious of and resolve their underlying fears, thus eliminating the need to convert anxiety into physical symptoms (Cretton et al., 2020; Levenson, 2020b; Stone & Sharpe, 2018). Alternatively, cognitive- behavioral therapists use exposure treatments. They 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 (Axelsson et al., 2020; Newby et al., 2018; Tsui et al., 2017). And

biological therapists most often use antidepressant drugs to help reduce anxiety and depression in patients with these disorders (Levenson, 2020b; Stone & Sharpe, 2018).

Other therapists try to address the physical symptoms of these disorders rather

than the causes, using techniques such as education, reinforcement, and cognitive restructuring. Those who employ education explain the disorder to patients, while also offering emotional support and hope that the physical

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symptoms may soon disappear. Therapists who take a reinforcement approach arrange for the removal of rewards for a client’s “sickness” symptoms and an increase of rewards for healthy behaviors. And those who offer cognitive restructuring guide clients to think differently about the nature and causes of

physical symptoms and illness. Researchers have not fully evaluated the effects of these approaches on conversion and somatic symptom disorders; several studies, however, have found them to be useful interventions (Cretton et al., 2020; Levenson, 2020b; Stone & Sharpe, 2018). It is also the case that antidepressant medications sometimes help alleviate the physical symptoms of people with these disorders in addition to reducing their feelings of anxiety and depression.

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Illness Anxiety Disorder

PEOPLE WITH illness anxiety disorder, previously known as hypochondriasis, are chronically anxious about their health and are convinced that they have or are developing a serious medical illness, despite the absence of somatic symptoms (see Table 9-5). They repeatedly check their body for signs of illness and misinterpret various bodily events as signs of serious medical problems. Typically the events are merely normal bodily changes, such as occasional coughing, sores, or sweating. Those with illness anxiety disorder persist in such misinterpretations no matter what friends, relatives, and physicians say. Some

such people recognize that their concerns are excessive, but many do not.

TABLE: 9-5

Checklist

Illness Anxiety Disorder

1. Person is preoccupied with thoughts about having or getting a significant illness. In reality, person has no or, at most, mild somatic symptoms.

2. Person has easily triggered high anxiety about health.

3. Person displays unduly high number of health-related behaviors (e.g., keeps focusing on body) or dysfunctional health-avoidance behaviors (e.g., avoids doctors).

4. Person’s concerns continue to some degree for at least 6 months.

Information from: APA, 2022.

Although illness anxiety disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers. Fewer than 1 percent of all people experience the disorder (French & Hameed, 2020; Levenson, 2020c). Physicians report seeing many cases. As many as 3 percent of

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all patients seen by primary care physicians may display this pattern. Their symptoms tend to rise and fall over the years.

Theorists typically explain illness anxiety disorder much as they explain anxiety- related disorders (see Chapter 5). Cognitive-behavioral theorists, for example, believe that (1) the illness fears are acquired through classical conditioning or modeling, and (2) people with the disorder are so sensitive to and threatened by bodily cues that they come to misinterpret them (French & Hameed, 2020; Arnáez et al., 2020).

People with illness anxiety disorder usually receive the kinds of treatments that are used to treat obsessive-compulsive disorder (see pages 141–144). Studies reveal, for example, that clients with the disorder often improve considerably when given the same antidepressant drugs that are helpful in cases of obsessive- compulsive disorder (French & Hameed, 2020). Many clients also improve when

treated with the cognitive-behavioral approach of exposure and response prevention. The therapists repeatedly point out bodily variations to the clients while, at the same time, preventing them from seeking their usual medical attention (Levenson, 2020d). In addition, the cognitive-behavioral therapists guide the clients to identify, challenge, and change their beliefs about illness that are helping to maintain their disorder.

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Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions

ABOUT 90 YEARS AGO, clinicians identified a group of physical illnesses that seemed to be caused or worsened by an interaction of biological, psychological, and sociocultural factors (Bott, 1928). Early editions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders, but DSM-5-TR labels them as psychological factors affecting other medical conditions (see Table 9-6). The more familiar term “psychophysiological” will be used in this chapter.

TABLE: 9-6

Checklist

Psychological Factors Affecting Other Medical Conditions

1. The presence of a medical condition.

2. Psychological factors negatively affect the medical condition by: Affecting the course of the medical condition. Providing obstacles for the treatment of the medical condition. Posing new health risks. Triggering or worsening the medical condition.

Information from: APA, 2022.

It is important to recognize that significant medical symptoms and conditions are involved in psychophysiological disorders and that the disorders often result in serious physical damage. They are different from the factitious, conversion,

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and illness anxiety disorders that are accounted for primarily by psychological factors.

Traditional Psychophysiological Disorders Before the 1970s, clinicians believed that only a limited number of illnesses were psychophysiological. The best-known and most common of these disorders were ulcers, asthma, insomnia, chronic headaches, high blood pressure, and

coronary heart disease. Recent research, however, has shown that many other physical illnesses — including bacterial and viral infections — may also be caused by an interaction of psychosocial and physical factors. Let’s look first at the traditional psychophysiological disorders and then at the illnesses that are newer to this category.

Ulcers are lesions (holes) that form in the wall of the stomach or of the duodenum, resulting in burning sensations or pain in the stomach, occasional vomiting, and stomach bleeding. More than 25 million people in the United States have ulcers at some point during their lives, and ulcers cause an estimated 6,500 deaths each year (Vakil, 2020). Ulcers often are caused by an interaction of stress factors, such as environmental pressure or intense feelings of anger or anxiety (see Figure 9-2), and physiological factors, such as the

bacteria H. pylori (Gillson, 2020; Lanas & Chan, 2017).

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FIGURE 9-2

What Do People Do to Relieve Stress?

According to a survey of 6,700 adults in the United States, people are most likely to listen to music or

watch television or videos when they are trying to reduce feelings of stress (Information from: Everyday

Health, 2018.)

Asthma causes the body’s airways (the trachea and bronchi) to narrow

periodically, making it hard for air to pass to and from the lungs. The resulting symptoms are shortness of breath, wheezing, coughing, and a terrifying choking sensation. Almost 25 million people in the United States currently suffer from asthma (CDC, 2020a), and most were children or young teenagers at the time of the first attack. Seventy percent of all cases appear to be caused by an interaction of stress factors, such as environmental pressures or anxiety, and physiological factors, such as allergies to specific substances, a slow-acting sympathetic nervous system, or a weakened respiratory system (Fanta, 2020;

Bass, 2019).

Insomnia, difficulty falling asleep or maintaining sleep, plagues one-third of the population each year (Bonnet & Arand, 2019). Although many of us have

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temporary bouts of insomnia that last a few nights or so, a large number of people — 10 percent of the population — have insomnia that lasts months or years (see InfoCentral). Chronic insomniacs feel as though they are almost constantly awake. They often are very sleepy during the day and may have

difficulty functioning. Their problem may be caused by a combination of psychosocial factors, such as high levels of anxiety or depression, and physiological problems, such as an overactive arousal system or certain medical ailments (Bonnet & Arand, 2020, 2019).

Chronic headaches are frequent intense aches of the head or neck that are not

caused by another physical disorder. There are two major types. Muscle contraction, or tension, headaches are marked by pain at the back or front of the head or the back of the neck. These occur when the muscles surrounding the skull tighten, narrowing the blood vessels. Over 45 million Americans suffer from such headaches repeatedly (NHF, 2020a).

Studying sleep This 5-year-old child is being hooked up to monitors so that he can undergo a polysomnographic examination, a procedure that measures physiological

activity during sleep, including measurements of brain, eye, lung, and heart activity.

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Migraine headaches are extremely severe, often nearly paralyzing, headaches that are located on one side of the head and are sometimes accompanied by dizziness, nausea, or vomiting. Migraine headaches are thought by some medical theorists to develop in two phases: (1) blood vessels in the brain narrow

so that the flow of blood to parts of the brain is reduced, and (2) the same blood vessels later expand so that blood flows through them rapidly, stimulating many neuron endings and causing pain. Thirty million people in the United States suffer from migraines each year (NHF, 2020a).

More than head pain Migraine headaches produce much more pain and a wider range of symptoms than most other kinds of headaches. Here, at a program in

Stockholm, Sweden, a mother massages the head of her young son, who suffers from migraines. Systematic

massaging is partially helpful to him during particularly severe episodes.

Research suggests that chronic headaches are caused by an interaction of stress factors, such as environmental pressures or general feelings of helplessness,

anger, anxiety, or depression, and physiological factors, such as abnormal activity of the neurotransmitter serotonin, vascular problems, or muscle weakness (NHF, 2020b; NINDS, 2020).

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Hypertension is a state of chronic high blood pressure. That is, the blood pumped through the body’s arteries by the heart produces too much pressure against the artery walls. Hypertension has few outward signs, but it interferes with the proper functioning of the entire cardiovascular system, greatly

increasing the likelihood of stroke, heart disease, and kidney problems. It is estimated that 77 million people in the United States have hypertension, thousands die directly from it annually, and millions more perish because of illnesses caused by it (Egan, 2020). Around 10 percent of all cases are caused by physiological abnormalities alone; the rest result from a combination of psychological and physiological factors and are called essential hypertension. Some of the leading psychosocial causes of essential hypertension are constant stress, environmental danger, and general feelings of anger or depression.

Physiological factors include obesity, smoking, poor kidney function, and an unusually high proportion of the gluey protein collagen in a person’s blood vessels (Basile & Bloch, 2019).

Coronary heart disease is caused by a blocking of the coronary arteries, the blood vessels that surround the heart and are responsible for carrying oxygen to

the heart muscle. The term actually refers to several problems, including blockage of the coronary arteries and myocardial infarction (a “heart attack”). In the United States, more than 28 million people currently have coronary heart disease. It is the leading cause of death for both men and women, accounting for 647,000 deaths each year (AHA, 2020; CDC, 2020b). If other heart-related diseases are added in, those numbers increase significantly. Approximately half of all middle-aged men and one-third of middle-aged women develop coronary heart disease at some point in their lives. The majority of all cases of this disease

are related to an interaction of psychosocial factors, such as job stress or high levels of anger or depression, and physiological factors, such as high cholesterol, obesity, hypertension, smoking, or lack of exercise (CDC, 2020b; Hennekens, 2020).

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What Factors Contribute to Psychophysiological Disorders?

Over the years, clinicians have identified a number of variables that may contribute to the development of psychophysiological disorders. The variables can be separated into biological, psychological, and sociocultural categories; however, variables from across these categories may interact to help produce psychophysiological disorders in the face of life stress, particularly chronic life stress (Young et al., 2020).

BIOLOGICAL FACTORS

You saw in Chapter 6 that one way the brain activates body organs is through the operation of the autonomic nervous system (ANS), the network of nerve fibers that connect the central nervous system to the body’s organs. Defects in this system are believed to contribute to the development of psychophysiological disorders (Seiler, Fagundes, & Christian, 2020; von Rosenberg, Hoting, & Mandic, 2019). If one’s ANS is stimulated too easily, for example, it may overreact to situations that most people find only mildly stressful, eventually damaging certain organs and causing a psychophysiological disorder. Other more specific

biological problems may also contribute to psychophysiological disorders. A person with a weak gastrointestinal system, for example, may be a prime candidate for an ulcer, whereas someone with a weak respiratory system may develop asthma readily.

INFOCENTRAL SLEEP AND SLEEP DISORDERS

Sleep is a naturally recurring state that features altered consciousness, suspension

of voluntary bodily functions, muscle relaxation, and reduced perception of environmental stimuli.

Researchers have acquired much data about the stages, cycles, brain waves, and mechanics of sleep,

but they do not fully understand its precise purpose. We do know, however, that humans and other

animals need sleep to survive and function properly.

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In a related vein, people may display favored biological reactions that raise their chances of developing psychophysiological disorders. Some individuals perspire in response to stress, others develop stomachaches, and still others have a rise in blood pressure. Research has indicated, for example, that some people are particularly likely to have temporary rises in blood pressure when stressed (Guo et al., 2020; Yuenyongchaiwat, 2017). It may be that they are prone to develop hypertension.

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PSYCHOLOGICAL FACTORS

According to many theorists, certain needs, attitudes, emotions, or coping styles may cause people to overreact repeatedly to stressors, and so increase their chances of developing psychophysiological disorders. Researchers have found, for example, that men with a repressive coping style (a reluctance to express discomfort, anger, or hostility) tend to have a particularly sharp rise in blood

pressure and heart rate when they are stressed (Mamilla et al., 2019; Howard, Myers, & Hughes, 2017).

Another personality style that may contribute to psychophysiological disorders is the Type A personality style, an idea introduced more than a half-century

ago by two cardiologists, Meyer Friedman and Ray Rosenman (1959). People with this style are said to be consistently angry, cynical, driven, impatient, competitive, and ambitious. They interact with the world in a way that, according to Friedman and Rosenman, produces continual stress and often leads to coronary heart disease. People with a Type B personality style, by contrast, are thought to be more relaxed, less aggressive, and less concerned about time and thus are less likely to develop cardiovascular deterioration.

The link between the Type A personality style and coronary heart disease has been supported by many studies. In one well-known investigation of more than 3,000 people, Friedman and Rosenman (1974) separated healthy men in their forties and fifties into Type A and Type B categories and then followed their health over the next 8 years. More than twice as many Type A men developed

coronary heart disease. Later studies found that Type A functioning correlates similarly with heart disease in women (Sahoo et al., 2018; Haynes et al., 1980).

Recent studies indicate that the link between the Type A personality style and heart disease may not be as strong as the earlier studies suggested. These

studies do suggest, however, that several of the characteristics that supposedly make up the Type A style, particularly hostility, competitiveness, and time urgency,

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may indeed be strongly related to heart disease (Hamieh et al., 2020; Tofler, 2019a).

A Type B sea turtle Most people have a pretty clear picture of a Type A personality, but have difficulty

spotting a Type B personality. They need look no farther than Crush, the ever-so-relaxed and laid-back

sea turtle in the animation films Finding Nemo and Finding Dori. Crush always goes with the flow and surfs

the seas at his own pace, repeatedly using terms like “Righteous” and “Duuuude” along the way.

SOCIOCULTURAL FACTORS: THE MULTICULTURAL PERSPECTIVE

Adverse social conditions may set the stage for psychophysiological disorders. Such conditions produce ongoing stressors that trigger and interact with the biological and personality factors just discussed. One of society’s most negative social conditions, for example, is poverty. In study after study, it has been found that impoverished people have more psychophysiological disorders, poorer

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health in general, and poorer health outcomes than wealthier people (CDF, 2020; HP, 2020a). One obvious reason for this relationship is that poor people typically experience higher rates of crime, job dissatisfaction, unemployment, overcrowding, and other negative stressors than wealthier people. In addition,

they typically receive inferior medical care.

Uncommon risk During the COVID-19 outbreak, a respiratory therapist administers

oxygen to a woman outside a medical facility in Oakland, California. African Americans have higher rates than non-Hispanic white Americans of COVID-19,

hypertension, asthma, heart disease, and HIV/AIDS — a race disparity attributed to poverty-linked living conditions, life stress, and low health care accessibility, among

other factors.

The relationship of race and ethnicity to psychophysiological and other health problems is complicated. On the one hand, as one might expect from the economic trends just discussed, African Americans have more health problems than do non-Hispanic white Americans. African Americans have, for example, higher rates of hypertension, diabetes, and asthma (OMH, 2020, 2019a, 2018). They are also more likely to die of heart disease, stroke, HIV/AIDS, and COVID- 19. Certainly, economic factors may help account for this racial difference. Many

African Americans live in poverty, and those who do often must contend with the high rates of crime and unemployment and limited health care access that contribute to poor health (PUSA, 2020).

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Research further suggests, however, that the high rate of psychophysiological and other medical disorders among African Americans may also relate to factors beyond the economic sphere. Consider, for example, the finding that 43 percent of African Americans have high blood pressure, compared with 29 percent of

non-Hispanic white Americans (OMH, 2020). Although this difference may once again be linked to economic factors, it may also be the case that African Americans have a physiological predisposition that increases their risk of developing high blood pressure. Or it may be that repeated experiences of racial discrimination constitute special stressors that raise blood pressure in African Americans (see Figure 9-3). Studies have found, for example, that the more discrimination people experience over a 1-year period, the greater their daily rise in blood pressure, and the more discrimination African Americans

experience over the course of their lives, the more likely they are to have high blood pressure in middle age and old age (Davis, 2020; HP, 2020b).

FIGURE 9-3

More Education, More Discrimination

In a large survey of African American adults, the majority of respondents said that they have experienced race-related discrimination, at least occasionally. Moreover,

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the college-educated respondents reported more experiences of discrimination than did the high school–educated respondents. (Information from: Pew Research

Foundation, 2019c.)

Looking at the health picture of African Americans, one might expect to find a similar trend among Hispanic Americans. After all, a high percentage of Hispanic Americans also live in poverty, are exposed to discrimination, are affected by high rates of crime and unemployment, and receive inferior medical care (Davis, 2020; PUSA, 2020). However, despite such disadvantages, the health of Hispanic

Americans is, on average, at least as good as (and often better than) that of both non-Hispanic white Americans and African Americans (Stickel et al., 2019). For example, Hispanic Americans have lower rates of high blood pressure and live longer.

The relatively positive health picture for Hispanic Americans in the face of economic disadvantage has been referred to in the clinical field as the “Hispanic Health Paradox.” Generally, researchers are puzzled by this pattern, but some explanations have been offered (Abraído-Lanza, Mendoza-Grey, & Flórez, 2020; Lee, 2020). It may be, for example, that the strong emphasis on social relationships, family support, and religiousness that often characterizes Hispanic American cultures increases health resilience among their members. Or Hispanic Americans may have a physiological predisposition that improves their

likelihood of having better health outcomes.

New Psychophysiological Disorders Clearly, biological, psychological, and sociocultural factors combine to produce psychophysiological disorders. In fact, the interaction of such factors is now considered the rule of bodily functioning, not the exception (Cazassa et al., 2020). As the years have passed, more and more illnesses have been added to the list of traditional psychophysiological disorders, and researchers have found many links between psychosocial stress and a wide range of physical illnesses. Let’s look at how these links were established and then at

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psychoneuroimmunology, the area of study that ties stress and illness to the body’s immune system.

Are Physical Illnesses Related to Stress?

Back in 1967 two researchers, Thomas Holmes and Richard Rahe, developed the Social Readjustment Rating Scale, which assigns numerical values to the stresses that most people experience at some time in their lives (see Table 9-7). Answers given by a large sample of participants indicated that the most stressful event on the scale is the death of a spouse, which receives a score of 100 life change units (LCUs). Lower on the scale is retirement (45 LCUs), and still lower is a minor violation of the law (11 LCUs). This scale gave researchers a yardstick for measuring the total amount of stress a person faces over a