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Anxiety Disorders :// 129

cording to research, such combinations often yield higher levels of symptom reduction and bring relief to more clients than do each of the approaches alone—improvements that may continue for years (Kordon et al., 2005; Rufer et al., 2005).

Obviously, the treatment picture for obsessive-compulsive disorder has improved greatly over the past 15 years, and indeed, this disorder is now helped by several forms of treatment, often used in combination. In fact, at least two studies suggest that the be- havioral, cognitive, and biological approaches may ultimately have the same effect on the brain. In these investigations, both participants who responded to cognitive-behavioral treatments and those who responded to antidepressant drugs showed marked reductions in activity in the caudate nuclei (Stein & Fineberg, 2007; Baxter et al., 2000, 1992).

Obsessive-Compulsive Disorder

People with obsessive -compulsive disorder experience obsessions and/or perform compulsions. Compulsions are often a response to a person's obsessive thoughts.

According to the psychodynamic view, obsessive-compulsive disorder arises out of an overt battle between id impulses and ego defense mechanisms. Behavior- ists, on the other hand, believe that compulsive behaviors develop through chance associations. The leading behavioral treatment combines prolonged exposure with response prevention. Cognitive theorists believe that obsessive-compulsive disorder grows from a normal human tendency to have unwanted and unpleasant thoughts. The misguided efforts of some people to understand, eliminate, or avoid such thoughts actually lead to obsessions and compulsions. Cognitive therapy for this dis- order includes correcting and helping clients change their misinterpretations of their unwanted thoughts. Research suggests that a combined cognitive-behavioral ap- proach often is more effective than either cognitive or behavioral therapy alone.

Biological researchers have tied obsessive-compulsive disorder to low serotonin activity and abnormal functioning in the orbitofrontal cortex, the caudate nuclei, or other regions in the obsessive-compulsive brain circuit. Antidepressant drugs that raise serotonin activity are a useful form of treatment.

PUTTING IT... together Diathesis-Stress in Action

Clinicians and researchers have developed many ideas about generalized anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder. At times, however, the sheer quantity of concepts and findings makes it difficult to grasp what is really known about the disorders.

Overall, it is fair to say that clinicians currently know more about the causes of phobias, panic disorder, and obsessive-compulsive disorder than about generalized anxiety disorder. It is worth noting that the insights about panic disorder and obsessive- compulsive disorder—once among the field's most puzzling patterns—did not emerge until clinical theorists took a look at the disorders from more than one perspective and integrated those views. Today's cognitive explanation of panic disorder, for example, builds squarely on the biological idea that the disorder begins with abnormal brain activity and unusual physical sensations. Similarly, the cognitive explanation of obsessive- compulsive disorder takes its lead from the biological position that some people are predisposed to experience more unwanted and intrusive thoughts than others.

It may be that a fuller understanding of generalized anxiety disorder awaits a similar integration of the various models. In fact, such an integration has already begun to unfold. Recall, for example, that one of the new wave cognitive explanations for generalized

130 ://CHAPTER 4

°stress management prograrn•An approach to treating generalized and other anxiety disorders that teaches clients techniques for reducing and con- trolling stress.

anxiety disorder links the cognitive process of worrying to heightened bodily arousal in individuals with the disorder.

Similarly, a growing number of theorists are adopting a diathesis-stress view of general- ized anxiety disorder. They believe that certain individuals have a biological vulnerability toward developing the disorder—a vulnerability that is eventually brought to the surface by psychological and sociocultural factors. Indeed, genetic investigators have discovered that certain genes may determine whether a person reacts to life's stressors calmly or in a tense manner, and developmental researchers have found that even during the earli- est stages of life some infants become particularly aroused when stimulated (Burijon, 2007; Kahn, 1993). Perhaps these easily aroused infants have inherited defects in GABA functioning or other biological limitations that predispose them to generalized anxiety disorder. If over the course of their lives, the individuals also face intense societal pres- sures, learn to interpret the world as a dangerous place, or come to regard worrying as a useful tool, they may be candidates for developing generalized anxiety disorder.

Diathesis-stress principles may also be at work in the development of phobias. Several studies suggest, for example, that certain infants are born with a style of social inhibition or shyness that may increase their risk of developing a social phobia (Smoller et al., 2003; Kagan & Snidman, 1999, 1991). Perhaps people must have both a genetic predisposition and unfortunate conditioning experiences if they are to develop particular phobias.

In the treatment realm, integration of the models is already on display for each of the anxiety disorders. Therapists have discovered, for example, that treatment is at least sometimes more effective when medications are combined with cognitive techniques to treat panic disorder and when medications are combined with cognitive-behavioral techniques to treat obsessive-compulsive disorder. Similarly, cognitive techniques are now often combined with relaxation training or biofeedback in the treatment of generalized anxiety disorder—a treatment package known as a stress management program (Lee et al., 2007; Taylor, 2006). And treatment programs for social phobias often include a combination of medications, exposure therapy, cognitive therapy, and social skills training. For the millions of people who suffer from these various anxiety disorders, such treat- ment combinations are a welcome development.

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fear, p. 95

generalized anxiety disorder, p. 96

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metacognitive and avoidance theories, pp. 100, 102

rational-emotive therapy, p. 102

mindfulness-based cognitive therapy, p. 103

family pedigree study, p. 104

benzodiazepines, p. 104

gamma-aminobutyric acid (GABA), p. 104

relaxation training, p. 105

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Anxiety Disorders :1/ 131

biofeedback, p. 105

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agoraphobia, p. 116

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biological challenge test, p. 118

anxiety sensitivity, p. 120

112 obsessive-compulsive disorder, p. 121

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Search the Fundamentals of Abnormal Psychology Video Tool Kit www.worthpublishers.com/apvtk

A Chapter 4 Video Cases

Worrying: Key to Generalized Anxiety Overcoming a Fear of Flying

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STRESS DISORDERS

pecialist Lovell Robinson, a 25-year-old single African American man, was an activated National Guardsman [serving in the Iraq war]. He [had been] a full-time college student and competitive athlete raised by a single mother in public housing. .

Initially trained in transportation, he was called to active duty and retrained as a military policeman to serve with his unit in Baghdad. He described enjoying the high intensity of his deployment and [became] recognized by others as an informal leader because of his aggres- siveness and self-confidence. He [had] numerous [combat] exposures while performing convoy escort and security details [and he came] under small arms fire on several occasions, witnessing dead and injured civilians and Iraqi soldiers and on occasion feeling powerless when forced to detour or take evasive action. He began to develop increasing mistrust of the [Iraq] environ- ment as the situation "on the street" seemed to deteriorate. He often felt that he and his fellow soldiers were placed in harm's way needlessly.

On a routine convoy mission [in 2003], serving as driver for the lead HUMVEE, his vehicle was struck by an Improvised Explosive Device showering him with shrapnel in his neck, arm, and leg. Another member of his vehicle was even more seriously injured. . . He was evacuated to the Combat Support Hospital (CSH) where he was treated and returned to duty ... after several days despite requiring crutches and suffering chronic pain from retained shrapnel in his neck. He began to become angry at his command and doctors for keeping him in [Iraq] while he was unable to perform his duties effectively. He began to develop insomnia, hypervigilance and a startle response. His initial dreams of the event became more intense and frequent and he suffered intrusive thoughts and flashbacks of the attack. He began to withdraw from his friends and suffered anhedonia, feeling detached from others, and he feared his future would be cut short. He was referred to a psychiatrist at the CSH. . .

After two months of unsuccessful rehabilitation for his battle injuries and worsening depressive and anxiety symptoms, he was evacuated to a . military medical center [in the United States]. . He was screened for psychiatric symptoms and was referred for outpatient evaluation and management. He met DSM-IV criteria for acute PTSD and was offered medication manage- ment, supportive therapy, and group therapy . . He was ambivalent about taking passes or convalescent leave to his home because of fears of being "different, irritated, or aggressive" around his family or girlfriend. After three months at the military service center, he was [deac- tivated from service and] referred to his local VA Hospital to receive follow-up care.

National Center for PTSD, 2008

During the horror of combat, soldiers often become highly anxious and depressed and physically ill. Moreover, for many, like Latrell, these reactions to extraordinary stress continue well beyond the combat experience itself.

But it is not just combat soldiers who are affected by stress. Nor does stress have to rise to the level of combat trauma to have a profound effect on psycho- logical and physical functioning. Stress comes in all sizes and shapes, and we are all greatly affected by it.

We feel some degree of stress whenever we are faced with demands or op- portunities that require us to change in some manner. The state of stress has two components: a stressoi; the event that creates the demands, and a stress response, the

TOPIC OVERVIEW Stress and Arousal: The Fight-or-Flight Response

The Psychological Stress Disorders: Acute and Posttraumatic Stress Disorders What Triggers a Psychological Stress Disorder?

Why Do People Develop a Psychological Stress Disorder?

How Do Clinicians Treat the Psychological Stress Disorders?

The Physical Stress Disorders: Psychophysiological Disorders Traditional Psychophysiological Disorders New Psychophysiological Disorders Psychological Treatments for Physical Disorders

Putting It Together: Expanding the Boundaries of Abnormal Psychology

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he Smell of Stress

1 34 ://CHAPTER 5

person's reactions to the demands. The stressors of life may include annoying everyday hassles, such as rush-hour traffic; turning-point events, such as college graduation or marriage; long-term problems, such as poverty or poor health; or traumatic events, such as major accidents, assaults, tornadoes, or military combat. Our response to such stressors is influenced by the way we judge both the events and our capacity to react to them in an effective way (Russo & Tartaro, 2008; Lazarus & Folkman, 1984). People who sense that they have the ability and the resources to cope are more likely to take stressors in stride and to respond well.

When we view a stressor as threatening, a natural reaction is arousal and a sense of fear—a response frequently on display in Chapter 4. As you saw in that chapter, fear is actually a package of responses that are physical, emotional, and cognitive. Physically, we per- spire, our breathing quickens, our muscles tense, and our hearts beat faster. Turning pale, developing goose bumps, and feeling nauseated are other physical reactions. Emotional responses to extreme threats include horror, dread, and even panic, while in the cognitive realm fear can disturb our ability to concentrate and distort our view of the world. We may exaggerate the harm that actually threatens us or remember things incorrectly.

Stress reactions, and the sense of fear they produce, are often at play in psychologi- cal disorders. People who experience a large number of stressful events are particularly vulnerable to the onset of the anxiety disorders that you read about in Chapter 4. Similarly, increases in stress have been linked to the onset of depression, schizophrenia, sexual dysfunctioning, and other psychological problems.

In addition, stress plays a more central role in certain psychological and physical disorders. In such disorders, the features of stress become severe and debilitating, linger for a long period of time, and may make it impossible for the individual to live a normal life. The key psychological stress disorders are acute stress disorder and posttraumatic stress disorder (PTSD). DSM-IV-TR technically lists these patterns as anxiety disorders, but as you will see, their features extend far beyond the symptoms of anxiety.The physical stress disorders are typically called psychophysiological disorders, problems that DSM-IV-TR now lists under the heading psychological factors qffecting medical condition. These psycho- logical and physical stress disorders are the focus of this chapter. Before examining them, however, you need to understand just how the brain and body react to stress.

*Stress and Arousal: The Fight-or-Flight Response The features of arousal and fear are set in motion by the brain area called the hypo- thalamus. When our brain interprets a situation as dangerous, neurotransmitters in the hypothalamus are released, triggering the firing of neurons throughout the brain and the release of chemicals throughout the body. Actually, the hypothalamus activates two

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Stress Disorders 1 35

important systems—the autonomic nervous system and the endocrine system, The auto- nomic nervous system (ANS) is the extensive network of nerve fibers that connect the central nervous system (the brain and spinal cord) to all the other organs of the body. These fibers help control the involuntary activities of the organs—breathing, heartbeat, blood pressure, perspiration, and the like (see Figure 5-1).The endocrine system is the network ofglands located throughout the body. (As you read in Chapter 2, glands release hormones into the bloodstream and on to the various body organs.) The autonomic ner- vous system. and the endocrine system often overlap in their responsibilities. There are two pathways, or routes, by which these systems produce arousal and fear reactions—the sympathetic nervous system pathway and the hypothalamic -pituitary-adrenal pathway.

When we face a dangerous situation, the hypothalamus first excites the sympathetic nervous system, a group of autonomic nervous system fibers that work to quicken our heartbeat and produce the other changes that we experience as fear or anxiety. These nerves may stimulate the organs of the body directly—for example, they may directly stimulate the heart and increase heart rate. The nerves may also influence the organs indirectly, by stimulating the adrenal glands (glands located on top of the kidneys), particularly an area of these glands called the adrenal medulla. When the adrenal medulla is stimulated, the chemicals epinephrine (adrenaline) and norepinephrine (noradrenaline) are released. You have already seen that these chemicals are important neurotransmitters when they operate in the brain (page 117). When released from the adrenal medulla,

'autonomic nervous system (ANS)• The network of nerve fibers that connect the central nervous system to all the other organs of the body.

'endocrine system•The system of glands located throughout the body that help control important activities such as growth and sexual activity.

"sympathetic nervous system•The nerve fibers of the autonomic nervous system that quicken the heartbeat and produce other changes experienced as arousal and fear.

1 36 ://CHAPTER 5

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however, they act as hormones and travel through the bloodstream to various organs and muscles, further producing arousal and fear.

When the perceived danger passes, a second group of autonomic nervous system fibers, called the parasympathetic nervous system, helps return our heartbeat and other body processes to normal. To- gether the sympathetic and parasympathetic nervous systems help control our arousal and fear reactions.

The second pathway by which arousal and fear reactions are pro- duced is the hypothalamic-pituitary-adrenal (HPA) pathway (see Figure 5-2). When we are faced by stressors, the hypothalamus also signals the pituitary gland, which lies nearby, to secrete the adreno- corticotropic hormone (ACTH), sometimes called the body's "major stress hormone." ACTH, in turn, stimulates the outer layer of the adrenal glands, an area called the adrenal cortex, triggering the release of a group of stress hormones called corticosteroids, including the hormone cortisol. These corticosteroids travel to various body organs, where they further produce arousal and fear reactions.

The reactions on display in these two pathways are collectively referred to as the fight - or-flight response, precisely because they arouse our body and prepare us for a response to danger. Each person has a particular pattern of autonomic and endocrine functioning and so a

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particular way of experiencing arousal and fear. Some people are almost always relaxed, while others typically feel tension, even when no threat is apparent. A person's general level of arousal and anxiety is sometimes called trait anxiety because it seems to be a general trait that each of us brings to the events in our lives (Spielberger, 1985, 1972, 1966). Psychologists have found that differences in trait anxiety appear soon after birth (Leonardo & Hen, 2006; Kagan, 2003).

People also differ in their sense of which situations are threatening (Fisher et al., 2004). Walking through a forest may be fearsome for one person but relaxing for an- other. Flying in an airplane may arouse terror in some people and boredom in others. Such variations are called differences in situation, or state, anxiety.

•parasympathetic nervous system. The nerve fibers of the autonomic ner- vous system that slow organ functioning after stimulation and return other bodily processes to normal.

•hypothalamic-pituitary-adrenal (HPA) pathwarOne route by which the brain and body produce arousal and fear.

•corticosteroids•A group of hormones, including cortisol, released by the adre- nal glands at times of stress.

'::.ifThe Psychological Stress Disorders: Acute and Posttraumatic Stress Disorders Of course when we actually confront stressful situations, we do not think to ourselves, "Oh, there goes my autonomic nervous system," or "My fight-or-flight seems to be kicking in." We just feel aroused psychologically and physically and experience a grow- ing sense of fear. If the stressful situation is truly extraordinary and unusually dangerous, we may temporarily experience levels of arousal, anxiety, and depression that are beyond anything we have ever known. For most people, such reactions subside soon after the danger passes. For others, however, the symptoms of anxiety and depression, as well as other kinds of symptoms, persist well after the upsetting situation is over. These people may be suffering from acute stress disorder or posttraumatic stress disorder; patterns that arise in reaction to a psychologically traumatic event. The event usually involves actual or threatened serious injury to the person or to a family member or friend. Unlike the anxiety disorders that you read about in Chapter 4, which typically are triggered by situations that most people would not find threatening, the situations that cause acute stress disorder or posttraumatic stress disorder—combat, rape, an earthquake, an airplane crash—would be traumatic for anyone (Burijon, 2007).

If the symptoms begin within four weeks of the traumatic event and last for less than a month, DSM-IV-TR assigns a diagnosis of acute stress disorder (APA, 2000). If the symptoms continue longer than a month, a diagnosis of posttraumatic stress disorder (PTSD) is given.The symptoms of PTSD may begin either shortly after the traumatic event or months or years afterward.

a

Stress Disorders :111 137

Studies indicate that as many as 80 percent of all cases of acute stress disorder develop into posttraumatic stress disorder (Burijon, 2007; Bryant et al., 2005). Think back to Latrell, the soldier in Iraq whose case opened this chapter. As you'll recall, Latrell became overrun by anxiety; insomnia, worry, anger, depression, irritability, intrusive thoughts, flashback memories, and social detachment within days of the attack on his convoy mission—thus qualifying him for a diagnosis of acute stress disorder. As his symptoms worsened and continued beyond one month—even long after his return to the United States—this diagnosis became PTSD. Aside from the differences in onset and duration, the symptoms of acute stress disorder and PTSD are almost identical.

Reexperiencing the traumatic event People may be battered by recurring thoughts, memories, dreams, or nightmares connected to the event (Clark, 2005).A few relive the event so vividly in their minds (flashbacks) that they think it is actually happen- ing again.

Avoidance People will usually avoid activities that remind them of the traumatic event and will try to avoid related thoughts, feelings, or conversations (Marx & Sloan, 2005).

Reduced responsiveness People feel detached from other people or lose interest in activities that once brought enjoyment. Some experience symptoms of dissociation, or psychological separation (Marx & Sloan, 2005): They feel dazed, have trouble remembering things, or have a sense of derealization (feeling that the environment is unreal or strange).

Increased arousal, anxiety, and guilt People with these disorders may feel overly alert (hyperalertness), be easily startled, have trouble concentrating, and develop sleep problems (Breslau et al., 2005). They may feel extreme guilt because they survived the traumatic event while others did not. Some also feel guilty about what they may have had to do to survive.

You can see these symptoms in the recollections of a Vietnam combat veteran years after he returned home:

can't get the memories out of my mind! The images come flooding back in vivid detail, triggered by the most inconsequential things, like a door slamming or the smell of stir- fried pork. Last night I went to bed, was having a good sleep for a change. Then in the early morning a storm-front passed through and there was a bolt of crackling thunder. I awoke instantly, frozen in fear. I am right back in Vietnam, in the middle of the monsoon season at my guard post. I am sure get hit in the next volley and convinced I will die. My hands are freezing, yet sweat pours from my entire body. l feel each hair on the back of my neck standing on end. I can't catch my breath and my heart is pounding. 1 smell a damp sulfur smell.

(Davis, 1992)

What Triggers a Psychological Stress Disorder? An acute or posttraumatic stress disorder can occur at any age, even in childhood, and can affect one's personal, family, social, or occupational life. People with these stress disorders may also experience depression, another anxiety disorder, or substance abuse or become suicidal (Koch & Haring, 2008). Surveys indicate that at least 3.5 percent of people in the United States experience one of the stress disorders in any given year; 7 to 9 percent suffer from one of them during their lifetimes (Taylor, 2010; Kessler et al., 2009, 2005). Around two-thirds of these individuals seek treatment at some point in their lives, but few do so when they first develop the disorder (Wang et al., 2005). Women are at least twice as likely as men to develop stress disorders: Around 20 percent

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Worst Natural Disasters of the Past 100 Years

Disaster Year Location Number Killed Flood 1931 Huang He River, China 3,700,000

Tsunami 2004 South Asia 280,000

Earthquake 1976 Tangshan, China 242,419

Heat wave 2003 Europe 35,000

Volcano 1985 Nevado del Ruiz, Colombia 23,000

Hurricane 1998 (Mitch) Central America 18,277

Landslide 1970 Yungay, Peru 17,500

Avalanche 1 916 Italian Alps 10,000

Blizzard 1972 Iran 4,000

Tornado 1989 Shaturia, Bangladesh 1,300

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of women who are exposed to a serious trauma may develop one, compared to 8 percent of men (Koch & Haring, 2008; Russo & Tartaro, 2008).

Any traumatic event can trigger a stress disorder; however, some are particularly likely to do so. Among the most con-unon are combat, disasters, and abuse and victimization.

Combat and Stress Disorders For years clinicians have recognized that many soldiers develop symptoms of severe anxiety and depression during combat. It was called "shell shock" during World War I and "combat fatigue" during World War II and the Korean War (Figley, 1978). Not until after the Vietnam War, however, did clinicians learn that a great many soldiers also experience serious psychological symptoms after combat (Koch & Haring, 2008).

By the late 1970s, it became apparent that many Vietnam combat veterans were still experiencing war-related psychological difficulties (Roy-Byrne et al., 2004). We now know that as many as 29 percent of all Vietnam veterans, male and female, suffered an acute or posttraumatic stress disorder, while another 22 percent experienced at least some stress symptoms (Krippner & Paulson, 2006;Weiss et al., 1992). In fact, 10 percent of the veterans of that war still experience posttraumatic stress symptoms, including flashbacks, night terrors, nightmares, and persistent images and thoughts.

A similar pattern is currently unfolding among veterans of the wars in Iraq and Afghanistan. In 2008, the RAND Corporation, a nonprofit research organization, com- pleted a large-scale study of military service members who have served in those two wars since 2001 (Geyer, 2008; RAND Corporation, 2008). It found that of the 1.6 million Americans deployed to the wars, nearly 20 percent have so far reported symptoms of posttraumatic stress disorder. Given that not all of the individuals studied were in fact ex- posed to prolonged periods of combat-related stress, this is indeed a very large percentage. Half of the veterans interviewed in this study described traumas in which they had seen friends seriously wounded or killed, 45 percent reported seeing dead or gravely wounded civilians, and 10 percent said they themselves had been injured and hospitalized.

It is also worth noting that the war in Iraq involves repeated deployments of many of the combat veterans and that those individuals who serve such multiple deployments are 50 percent more likely than those with one tour of service to experience severe combat stress, significantly raising their risk of developing posttraumatic stress disorder (Tyson, 2006).

Disasters and Stress Disorders Acute and posttraumatic stress disorders may also follow natural and accidental disasters such as earthquakes, floods, tornadoes, fires, airplane crashes, and serious car accidents (see Table 5-1). In fact, because they occur more often,

civilian traumas have been the trigger of stress disorders

138 ://CHAPTER 5

at least 10 times as often as combat traumas (Bremner, 2002). Studies have found, for example, that as many as 40 percent of victims of serious traffic accidents—adult or child—may develop PTSD within a year of the accident (Hickling & Blanchard, 2007).

Victimization and Stress Disorders People who have been abused or victimized often experience linger- ing stress symptoms. Research suggests that more than one-third of all victims of physical or sexual assault de- velop posttraumatic stress disorder (Burijon, 2007). Simi- larly, as many as half of all people who are directly exposed to terrorism or torture may develop this disorder (Basoglu et al., 2001).

SEXUAL ASSAULT A common form of victimization in our society today is sexual assault. Rape is forced sexual intercourse or another sexual act committed against a nonconsenting person or intercourse with an underage

Stress Disorders :1/ 1 39

person. Surveys suggest that in the United States more than 300,000 persons are victims of rape or attempted rape each year (Ahrens et al., 2008). Most rapists are men and most victims are women. Around 1 in 6 women is raped at some time during her life (Ahrens et al., 2008). Surveys also suggest that most rape victims are young: 29 percent are under 11 years old, 32 percent are between the ages of 11 and 17, and 29 percent are between 18 and 29 years old. Approximately 70 percent of the victims are raped by acquaintances or relatives (Ahrens et al., 2008).

The rates of rape appear to differ from race to race. In 2000, 46 percent of rape victims in the United States were white American, 27 percent were African American, and 19 percent were Hispanic American (Ahrens et al., 2008; Tjaden & Thoennes, 2000). These rates were in marked contrast to the 2000 general population distribution of 75 percent white American, 12 percent African American, and 13 percent Hispanic American.

The psychological impact of rape on a victim is immediate and may last a long time (Russo & Tartar°, 2008; Koss, 2005, 1993). Rape victims typically experience enormous distress during the week after the assault. Stress continues to rise for the next 3 weeks, maintains a peak level for another month or so, and then starts to improve. In one study, 94 percent of rape victims fully qualified for a clinical diagnosis of acute stress disorder when they were observed around 12 days after the assault (Rothbaum et al., 1992). Although most rape victims improve psychologically within 3 or 4 months, the effects may persist for up to 18 months or longer. Victims typically continue to have higher- than-average levels of anxiety, suspiciousness, depression, self-esteem problems, self-blame, flashbacks, sleep problems, and sexual dysfunction (Ahrens et al., 2008). The lingering psychological impact of rape is apparent in the following case description:

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Mary Billings is a 33-year-old divorced nurse, referred to the Victim Clinic at Bedford Psy- chiatric Hospital for counseling by her supervisory head nurse. Mary had been raped two months ago. The assailant gained entry to her apartment while she was sleeping, and she awoke to find him on top of her. He was armed with a knife and threatened to kill her and her child (who was asleep in the next room) if she did not submit to his demands. He forced her to undress and repeatedly raped her vaginally over a period of I hour. He then admonished her that if she told anyone or reported the incident to the police he would return and assault her child.

After he left, she called her boyfriend, who came to her apartment right away. He helped her contact the Sex Crimes Unit of the Police Department, which is currently investigating the case. He then took her to a local hospital for a physical examination and collection of evidence for the police (traces of sperm, pubic hair samples, fingernail scrapings). She was given antibiotics as prophylaxis against venereal disease. Mary then returned home with a girlfriend who spent the remainder of the night with her.

Over the next few weeks Mary continued to be afraid of being alone and had her girl- friend move in with her. She became preoccupied with thoughts of what had happened to her and the possibility that it could happen again. Mary was frightened that the rapist might return to her apartment and therefore had additional locks installed on both the door and the windows. She was so upset and had such difficulty concentrating that she decided she could not yet return to work. When she did return to work several weeks later, she was still clearly upset, and her supervisor suggested that she might be helped by counseling.

During the clinic interview, Mary was coherent and spoke quite rationally in a hushed voice. She reported recurrent and intrusive thoughts about the sexual assault, to the extent that her concentration was impaired and she had difficulty doing chores such as making meals for herself and her daughter. She felt she was not able to be effective at work, still

•rape•Forced sexual intercourse or another sexual act committed against a nonconsenting person or intercourse with an underage person.

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felt afraid to leave her home, to answer her phone, and had little interest in contacting friends or relatives.

.. [Mary] talked in the same tone of voice whether discussing the assault or less emotionally charged topics, such as her work history. She was easily startled by an un- expected noise. She also was unable to fall asleep because she kept thinking about the assault. She had no desire to eat, and when she did attempt it, she felt nauseated. Mary was repelled by the thought of sex and stated that she did not want to have sex for a long time, although she was willing to be held and comforted by her boyfriend.

(Spitzer et al., 1983, pp. 20-21)

Although many rape victims are severely injured by their attacker or experience other physical problems as a result of their assault, only half receive the kind of formal medical care afforded Mary (Logan et al., 2006). Between 4 and 30 percent of victims develop a sexually transmitted disease (Koss, 1993; Murphy, 1990) and 5 percent become pregnant (Beebe, 1991; Koss et al., 1991), yet surveys reveal that 60 percent of rape victims fail to receive pregnancy testing, preventive measures, or testing for exposure to HIV (National Victims Center, 1992).

Female victims of rape and other crimes are also much more likely than other women to suffer serious long-term health problems (Leibowitz, 2007; Koss & Heslet, 1992). In- terviews with 390 women revealed that such victims had poorer physical well-being for at least five years after the crime and made twice as many visits to physicians.

As you will see in Chapter 14, ongoing victimization and abuse in the family— specifically child and spouse abuse—may also lead to psychological stress disorders. Be- cause these forms of abuse may occur over the long term and violate family trust, many victims develop other symptoms and disorders as well (Dietrich, 2007; Woods, 2005).

TERRORISM People who are victims of terrorism or who live under the threat of terror- ism often experience posttraumatic stress symptoms (La Greca & Silverman, 2009; Galea et al., 2007). Unfortunately, this source of traumatic stress is on the rise in our society. Few will ever forget the events of September 11, 2001, when hijacked airplanes crashed into and brought down the World Trade Center in NewYork City and partially destroyed the Pentagon in Washington, DC, killing thousands of victims and rescue workers and forcing thousands more to desperately run, crawl, and even dig their way to safety. One of the many legacies of this infamous event is the lingering psychologi- cal effect, particularly severe stress reactions, that it has had on those people who were immediately affected, on their family members, and on tens of millions of others who were traumatized simply by watching images of the disaster on their television sets as the day unfolded. Studies of subsequent acts of terrorism, such as the 2004 commuter train bombings in Madrid and the 2005 London subway and bus bombings, tell a similar story (Charon &Vecina, 2007).

TORTURE Torture refers to the use of "brutal, degrading, and disorienting strategies in order to reduce victims to a state of utter helplessness" (Okawa & Hauss, 2007). Often, it is done on the orders of a government or another authority to force persons to yield information or make a confession (Gerrity, Keane, &Tuma, 2001). The question of the morality of torturing prisoners who are considered suspects in the "war on terror" has been the subject of much discussion over the past few years (Okawa & Hauss, 2007; Danner, 2004).

It is hard to know how many people are in fact tortured around the world because such numbers are typically hidden by governments (Basoglu et al., 2001). It has been estimated, however, that between 5 and 35 percent of the world's 15 million refugees have suffered at least one episode of torture and that more than 400,000 torture survi- vors from around the world now live in the United States (ORR, 2006;AI, 2000; Baker, 1992). Of course, these numbers do not take into account the many thousands of victims who have remained in their countries even after being tortured.

40 ://CHAPTER 5

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1 3r 11, 2001: The Psychological Aftermath n September 11, 2001, the United States experienced the most cata-

strophic act of terrorism in history when four commercial airplanes were hijacked and three of them were crashed into the twin towers of the World Trade Center in New York City and the Pentagon in Washington, DC. Studies conducted since that fateful day have confirmed what psychologists knew all too well would happen—that in the aftermath of Septem- ber 11, many individuals experienced immediate and long-term psychological effects, ranging from brief stress reac- tions, such as shock, fear, and anger, to enduring psychological disorders, such as posttraumatic stress disorder (Galea et al., 2007; Tramontin & Hcilpern, 2007).

reactions (Tramontin & Halpern, 2007; Adorns & Boscarino, 2005; Blanchard et al., 2005). Indeed, even years after the attacks, 42 percent of all adults in the United States and 70 percent of all New York adults report high terrorism fears; 23 percent of all adults in the United States report feeling less safe in their homes; 15 percent of all U.S. adults report drink- ing more alcohol than they did prior to the attacks; and 9 percent of New York adults display PTSD, compared to the national annual prevalence of 3.5 percent.

In a survey conducted the week after the terrorist attacks, 560 ran- domly selected adults across the United States were interviewed. Forty-four percent of them reported substantial stress symptoms; 90 percent reported at least some increase in stress (Schuster et al., 2001). Individuals closest to the disaster site experienced the great- est stress reactions, but millions of other people who had remained glued to their TV sets throughout the day experienced stress reactions and disorders as well.

Follow-up studies suggest that many such individuals continue to struggle with terrorism-related stress

Stress Disorders 141

People from all walks of life are subjected to torture worldwide—from suspected terrorists to student activists and members of religious, ethnic, and cultural minority groups.The techniques used on them may include physical torture (beatings, waterboard- ing, electrocution), psychological torture (threats of death, mock executions, verbal abuse, degradation), sexual torture (rape, violence to the genitals, sexual humiliation), or torture through deprivation (sleep, sensory, social, nutritional, medical, or hygiene deprivation).

Torture victims often experience physical ailments as a result of their ordeal, from scarring and fractures to neurological problems and chronic pain. But many theorists believe that the lingering psychological effects of torture are even more problematic (Okawa & Flauss, 2007; Basoglu et al., 2001). It appears that between 30 and 50 per- cent of torture victims develop posttraumatic stress disorder (Basoglu et al., 2001). Even for those who do not develop a full-blown disorder, symptoms such as nightmares,

•torture•The use of brutal, degrading, and disorienting strategies to reduce victims to a state of utter helplessness.

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flashbacks, repressed memories, depersonalization, poor concentration, anger outbursts, sadness, and suicidal thoughts are common (Okawa & Hauss, 2007; Okawa et al., 2003; Ortiz, 2001).

by Do People Develop a Psychological Stress Disorder? Clearly, extraordinary trauma can cause a stress disorder. The stressful event alone, how- ever, may not be the entire explanation. Certainly, anyone who experiences an unusual trauma will be affected by it, but only some people develop a stress disorder (Koch & Haring, 2008).To understand the development of these disorders more fully, researchers have looked to the survivors' biological processes, personalities, childhood experiences, social support systems, and cultural backgrounds and to the severity of the traumas.

Biological and Genetic Factors Investigators have learned that traumatic events trigger physical changes in the brain and body that may lead to severe stress reactions and, in some cases, to stress disorders.They have, for example, found abnormal activity of the hormone cortisol and the neurotransmitter/hormone norepinephrine in the urine, blood, and saliva of combat soldiers, rape victims, concentration camp survivors, and survivors of other severe stresses (Burij on, 2007; Delahanty et al., 2005).

Evidence from brain studies also shows that once a stress disorder sets in, individu- als experience further biochemical arousal and this continuing arousal may eventually damage key brain areas (Carlson, 2008; Mirzaei et al., 2005).Two areas in particular seem to be affected—the hippocampus and the amygdala. Normally, the hippocampus plays a major role both in memory and in the regulation of the body's stress hormones. Clearly, a dysfunctional hippocampus may help produce the intrusive memories and constant arousal found in posttraumatic stress disorder (Bremner et al., 2004). Similarly, as you observed in Chapter 4, the amygdala helps control anxiety and other emotional responses. It also works with the hippocampus to produce the emotional components of memory. Thus, a dysfunctional amygdala may help produce the repeated emotional symptoms and strong emotional memories experienced by persons with posttraumatic stress disorder (Protopopescu et al., 2005). In short, the arousal produced by extraordinary traumatic events may lead to stress disorders in some people, and the stress disorders may produce yet further brain abnormalities, locking in the disorders all the more firmly.

It may also be that posttraumatic stress disorder leads to the transmission of bio- chemical abnormalities to the children of persons with the disorder. One team of researchers examined the cortisol levels of women who had been pregnant during the September 11, 2001, terrorist attacks and had developed PTSD (Yehuda & Bierer, 2007). Not only did these women have higher-than-average cortisol levels, but the babies to

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whom they gave birth after the attacks also displayed higher cortisol levels, suggesting that the babies inherited a predisposition to develop the same disorder.

Many theorists believe that people whose biochemical reactions to stress are un- usually strong are more likely than others to develop stress disorders (Carlson, 2008; Burijon, 2007). But why would certain people be prone to such strong biological reac- tions? One possibility is that the propensity is inherited. Clearly, this is suggested by the mother-offspring studies just discussed. Similarly, studies conducted on thousands of pairs of twins who have served in the military find that if one twin develops stress symptoms after combat, an identical twin is more likely than a fraternal twin to develop the same problem (Koenen et al., 2003; True & Lyons, 1993).

Personali Some studies suggest that people with certain personalities, attitudes, and coping styles are particularly likely to develop stress disorders (Burijon, 2007; Chung et al., 2005). In the aftermath of Hurricane Hugo in 1989, for example, children who had been highly anxious before the storm were more likely than other children to develop severe stress reactions (Hardin et al., 2002). Research has also found that people who generally view life's negative events as beyond their control tend to develop more severe stress symptoms after sexual or other kinds of criminal assaults than people who feel greater control over their lives (Taylor, 2006; Bremner, 2002). Similarly, individuals who generally find it difficult to derive anything positive from unpleasant situations adjust more poorly after traumatic events than people who are generally resilient and who typi- cally find value in negative events (Bonanno, 2004).

Childhood Experiences Researchers have found that certain childhood experi- ences seem to leave some people at risk for later acute and posttraumatic stress disorders. People whose childhoods have been marked by poverty appear more likely to develop these disorders in the face of later trauma. So do people whose family members suffered from psychological disorders; who experienced assault, abuse, or catastrophe at an early age; or who were younger than 10 when their parents separated or divorced (Koch & Haring, 2008; Koopman et al., 2004).

Social Support It has been found that people whose social and family support sys- tems are weak are also more likely to develop a stress disorder after a traumatic event (Charuvastra & Cloitre, 2008; Ozer, 2005) . Rape victims who feel loved, cared for, valued, and accepted by their friends and relatives recover more successfully. So do those treated with dignity and respect by the criminal justice system (Murphy, 2001). In contrast, clini- cal reports have suggested that poor social support contributes to the development of posttraumatic stress disorder in some combat veterans (Charuvastra & Cloitre, 2008).

Multicultural Factors There is a growing suspicion among clinical researchers that the rates of posttraumatic stress disorder may differ from ethnic group to ethnic group in the United States. In particular, Hispanic Americans may have a greater vulnerability to the disorder than other cultural groups (Koch & Haring, 2008; Galea et al., 2006). Some cases in point: (1) Studies of combat vet- erans from the wars in Vietnam and Iraq have found higher rates of post- traumatic stress disorder among Hispanic American veterans than among white American and African American veterans (RAND Corporation, 2008; Kulka et al., 1990). (2) In surveys of police officers, Hispanic Amer- ican officers typically report more severe duty-related stress symptoms than their non-Hispanic counterparts (Pole et al., 2001). (3) Data on hurricane victims reveal that after some hurricanes Hispanic American victims have had a significantly higher rate of PTSD than victims from other ethnic groups (Perilla et al., 2002). (4) Surveys of New York City residents conducted in the months following the terrorist attacks of Sep- tember 11, 2001, revealed that 14 percent of Hispanic American residents developed PTSD, compared to 9 percent of African American residents and 7 percent of white American residents (Galea et al., 2002).

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Why might Hispanic Americans be more vulnerable to posttraumatic stress disorder than other racial or ethnic groups? Several explanations have been suggested. One holds that as part of their cultural belief system, many Hispanic Americans tend to view trau- matic events as inevitable and unalterable, a coping response that may heighten their risk for posttraumatic stress disorder (Perilla et al., 2002). Another explanation suggests that their culture's emphasis on social relationships and social support may place Hispanic American victims at special risk when traumatic events deprive them—temporarily or permanently—of important relationships and support systems. Indeed, a study con- ducted more than two decades ago found that among Hispanic American Vietnam combat veterans with stress disorders, those with poor family and social relationships suffered the most severe symptoms (Escobar et al., 1983).

Severity of Trauma As you expect, the severity and nature of traumatic events help determine whether one will develop a stress disorder. Some events can override even a nurturing childhood, positive attitudes, and social support (Tramontin & Halpern, 2007). One study examined 253 Vietnam War prisoners five years after their release. Some 23 percent qualified for a clinical diagnosis, though all had been evaluated as well adjusted before their imprisonment (Ursano et al., 1981).

Generally, the more severe the trauma and the more direct one's exposure to it, the greater the likelihood of developing a stress disorder (Burijon, 2007). Mutilation and severe physical injury in particular seem to increase the risk of stress reactions, as does witnessing the injury or death of other people (Koren et al., 2005; Ursano et al., 2003).

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How Do Clinicians Treat the Psychological Stress Disorders? Treatment can be very important for persons who have been overwhelmed by traumatic events (Taylor, 2010; DeAngelis, 2008). Overall, about half of all cases of posttraumatic stress disorder improve within six months (Asnis et al., 2004). The remainder of cases may persist for years, and, indeed, more than one-third of people with PTSD fail to respond to treatment even after many years (Burijon, 2007).

Today's treatment procedures for troubled survivors typically vary from trauma to trauma. Was it combat, an act of terrorism, sexual molestation, or a major accident? Yet all the programs share basic goals: They try to help survivors put an end to their stress reactions, gain perspective on their painful experiences, and return to constructive living (Taylor, 2010; Ehlers et al., 2005). Programs for combat veterans who suffer from PTSD illustrate how these issues may be addressed.

Treatment for Combat Veterans Therapists have used a variety of techniques to reduce veterans' posttraumatic symptoms. Among the most common are drug therapy behavioral exposure techniques, insight therapy, family therapy, and group therapy. Typically the

approaches are combined, as no one of them successfully reduces all the symptoms (DeAngelis, 2008; Munsey, 2008).

Antianxiety drugs help control the tension that many veterans ex- perience. In addition, antidepressant medications may reduce the occur- rence of nightmares, panic attacks, flashbacks, and feelings of depression (Koch & Hating, 2008; Davidson et al., 2005).

Behavioral exposure techniques, too, have helped reduce specific symptoms, and they have often led to improvements in overall adjust- ment (Koch & Haring, 2008). In fact, some studies indicate that expo- sure treatment is the single most helpful intervention for persons with stress disorders (Wiederhold &Wiederhold, 2005).This finding suggests to many clinical theorists that exposure of one kind or another should always be part of the treatment picture. In one case, the exposure tech- nique of flooding, along with relaxation training, helped rid a 31-year- old veteran of frightening flashbacks and nightmares (Fairbank & Keane, 1982).The therapist and the veteran first singled out combat scenes that the man had been reexperiencing frequently.The therapist then helped

Media

HOME SEND

Combat Trauma Takes the Stand BY DEBORAH SONTAG AND LIZETTE ALVAREZ,

NEW YORK TIMES, JANUARY 27,200B

hen it came time to sentence James Allen Gregg for his conviction on murder charges, the judge in South Dakota

took a moment to reflect on the defendant as an Iraq combat veteran who suffered from severe post-traumatic stress disorder. "This is a terrible case, as all here have observed," said Judge Charles B. Kornmann of United States District Court. "Obviously not all the casualties coming home from Iraq or Afghanistan come home in body bags.".

When combat veterans like Mr. Gregg stand accused of killings and other offenses on their return from Iraq and Afghani- stan, prosecutors, judges and juries are increasingly prodded to assess the role of combat trauma in their crimes. . . [M]ore and more, with the troops' mental health a rising concern, these defendants .. . are arguing that war be seen as the backdrop for these crimes, most of which are committed by individuals without criminal records. . . "I think they should always re- ceive sonic kind of consideration for the fact that their mind has been broken by war," said [a] Western regional defense counsel for the Marines. . . .

On the evening of July 3, 2004, Mr. Gregg, then 22, spent the night with friends in a roving pre-Independence Day celebra- tion on the reservation where he grew up, part of a small non- Indian population. They drank at a Quonset but bar ... and finally at a mint farm where they built a bonfire, roasted marsh- mallows and made s'mores.

According to the prosecutor, Mr. Gregg got upset because a young woman accompanying him gravitated to another man. This, the prosecutor said, led to Mr. Gregg spinning the wheels of his truck and spraying gravel on a car belonging to James Fallis, 26, a former high school football lineman. . . . Some time later, a confrontation ensued. Mr. Gregg was severely beaten

Stress Disorders :// 145

the veteran to imagine one of these scenes in great detail and urged him to hold on to the image until his anxiety stopped.After each of these flooding exercises, the therapist had the veteran switch to a positive image and led him through relaxation exercises.

A widely applied form of exposure therapy is eye movement desensitization and reprocessing (EMDR), in which clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of the objects and situations they ordinarily try to avoid. Case studies and controlled studies suggest that this treatment can often be helpful to persons with posttraumatic stress disorder (Luber, 2009). Many theorists argue that it is the exposure feature of EMDR, rather than the eye movement, that accounts for its success with the disorder (Lamprecht et al., 2004).

Although drug therapy and exposure techniques bring some relief, most clinicians believe that veterans with posttraumatic stress disorder cannot fully recover with these approaches alone:They must also come to grips in some way with their combat experi- ences and the impact those experiences continue to have (Burijon, 2007).Thus clinicians

°eye movement desensitization and reprocessing (EMDR).A behavioral exposure treatment in which clients move their eyes in a saccadic (rhythmic) man- ner from side to side while flooding their minds with images of objects and situa- tions they ordinarily avoid.

EXPLORE

by Mr. Fallis and, primarily, by another man, suffering facial fractures. Later that night, with one eye swollen shut and a fat lip, he drove to Mr. Fallis's neighborhood.

Mr. Fallis emerged from a trailer, removed his jacket, asked Mr. Gregg if he had come back for more and opened the door to Mr. Gregg's pickup truck. Mr. Gregg then reached for the pistol that he carried with him after his return from Iraq. He pointed it at Mr. Fallis and warned him to back away. Mr. Fallis moved toward the trunk of his car, and Mr. Gregg testified that he believed Mr. Fallis was going to get a weapon. He started shooting to stop him, he said, and then Mr. Fallis veered toward his house. Mr. Gregg fired nine times, and struck [and killed] Mr. Fallis with five bullets.

Mr. Gregg drove quickly away, ending up in a pasture near his parents' house. According to Mr. Gregg's testimony, he then put a magazine of more bullets in his gun, chambered a round and pointed it at his chest. "Jim, why were you going to kill yourself?" his lawyer asked in courf. . . . "Because it felt like Iraq had come back," Mr. Gregg said. "I felt hopeless. . . . I never wanted to shoot him. Never wanted to hurt him. Never. Everything happened just so fast. I mean, it was almost instinct that I had to protect myself."

Mental health experts for the defense said, as one psychiatrist testified, that "PTSD was the driving force behind Mr. Gregg's actions" when he shot his victim. Having suffered a severe beating, they said, he experienced an exaggerated "startle reaction"—a characteristic of PTSD—when Mr. Fallis reached for his car door, and responded instinctively... ,

The jury found Mr. Gregg guilty of second-degree but not first-degree murder. . . . The Sentence: 21 Years. . . If all efforts to free him fail, he is projected to be released on July 22, 2023, a few weeks shy of his 42nd birthday.

Copyright CD 2008 New York Times. All rights reserved. Reprinted by permission of PARS International, Inc.

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•rap group•A group that meets to talk about and explore members' problems in an atmosphere of mutual support.

• sychological debriefing•A form of crisis intervention in which victims are helped to talk about their feelings and reactions to traumatic incidents. Also called critical incident stress debriefing,

often try to help veterans bring out deep-seated feelings, accept what they have done and experienced, become less judgmental of themselves, and learn to trust other people once again (Turner et al., 2005). In a similar vein, cognitive therapists typically guide such veterans to examine and change the dysfunctional attitudes and styles of interpretation that have emerged as a result of their traumatic experiences (DeAngelis, 2008).

Veterans who have a psychological stress disorder may be further helped in a couple, family, or group therapy format (DeAngelis, 2008; Johnson, 2005). The symptoms of posttraumatic stress disorder are particularly apparent to family members, who may be directly affected by the client's anxieties, depressive mood, or angry outbursts.With the help and support of their family members, individuals may come to examine their im- pact on others, learn to communicate better, and improve their problem-solving skills.

In group therapy, often provided in a form called rap groups, the veterans meet with others like themselves to share experiences and feelings (particularly guilt and rage), develop insights, and give mutual support (Burijon, 2007; Lifton, 2005).

Today hundreds of small Veterans Outreach Centers across the country, as well as treat- ment programs in Veterans Administration hospitals and mental health clinics, provide group treatments (Welch, 2007).These agencies also offer individual therapy, counseling for spouses and children, family therapy, and aid in seeking jobs, education, and benefits. Clinical reports suggest that these programs offer a necessary, sometimes life-saving, treatment opportunity.

Psychological Debriefing: The Sociocultural Model in Action People who are traumatized by disasters, victimization, or accidents profit from many of the same treatments that are used to help survivors of combat. In addition, because their traumas occur in their own community, where mental health resources are close at hand, these individuals may, according to many clinicians, further benefit from immediate commu- nity interventions. The leading such approach is called psychological debriefing, or critical incident stress debriefing.

Psychological debriefing is actually a form of crisis intervention that has victims of trauma talk extensively about their feelings and reactions within days of the critical incident (Mitchell, 2003, 1983). Because such sessions are expected to prevent or reduce stress reactions, they are often applied to victims who have not yet displayed any symp-

Stress Disorders 147

toms at all, as well as those who have. During the sessions, often conducted in a group format, counselors guide the individuals to describe the details of the recent trauma, to vent and relive the emotions provoked at the time of the event, and to express their current feelings. The clinicians then clarify to the victims that their reactions are perfectly normal responses to a terrible event, offer stress management tips, and, when necessary, refer the victims to professionals for long-term counseling.

Thousands of counselors, both professionals and nonprofes- sionals, are now trained in psychological debriefing each year, and the intense approach has been applied in the aftermath of countless traumatic events (McNally, 2004).When the traumatic incident affects numerous individuals, debriefing-trained coun- selors may come from far and wide to conduct debriefing ses- sions with the victims. One of the largest mobilization programs of this kind is the Disaster Response Network (DRN), developed by the American Psychological Association and the American Red Cross. The network is made up of several thousand volun- teer psychologists who have offered free emergency mental health services at disaster sites such as the 1999 shooting of 23 persons at Columbine High School in Colorado, the 2001 World Trade Center attack, the 2004 tsunami in South Asia, and the floods caused by Hurricane Katrina in 2005 (APA, 2008, 2005).

In such community-wide mobilizations, the counselors may knock on doors or approach victims at shelters. Although victims from all socioeconomic groups may be engaged, sonic theorists believe that those who live in poverty are in particular need of such community-level interventions. Relief workers, too, can become overwhelmed by the traumas they witness (Carl, 2007).

Does Psychological Debriefing Work? Research and personal testimonials for rapid mobilization programs have often been favorable (Watson & Shalev, 2005; Mitchell, 2003). Nevertheless, a number of studies have called into question the effectiveness of these kinds of interventions (Pender & Prichard, 2009; Tramontin & Halpern, 2007).

An investigation conducted in the early 1990s was among the first to raise con- cerns about disaster mental health programs (Bisson & Deahl, 1994). Crisis counselors offered debriefing sessions to 62 British soldiers whose job during the GulfWar was to handle and identify the bodies of individuals who had been killed. Despite such sessions, half of the soldiers displayed posttraumatic stress symptoms when interviewed nine months later.

In a properly controlled study conducted a few years later on hospitalized burn vic- tims, researchers separated the victims into two groups (Bisson et al., 1997). One group received a single one-on-one debriefing session within days of their burn accidents, while the other (control) group of burn victims received no such intervention. Three months later, it was found that the debriefed and the control patients had similar rates of posttraurnatic stress disorder. Moreover, researchers found that 13 months later, the rate of posttraumatic stress disorder was actually higher among the debriefed burn victims (26 percent) than among the control victims (9 percent).

Several other studies, focusing on yet other kinds of disasters, have yielded similar patterns of findings (Van Emmerik et al., 2002). Obviously, these studies raise serious questions about the effectiveness of psychological debriefing. Some clinicians believe that the early intervention programs may encourage victims to dwell too long on the traumatic events that they have experienced. And a number worry that early disaster counseling may unintentionally "suggest" problems to victims, thus helping to produce stress disorders in the first place (McNally, 2004; McClelland, 1998).

The current clinical climate continues to favor disaster counseling. However, the concerns that have been raised merit serious consideration.We are reminded here, as else- where, of the constant need for careful research in the field of abnormal psychology.

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148 :it/CHAPTER 5

.psychophysiological disorders. Illnesses that result from an interaction of psychosocial and organic factors. Also known as psychosomatic disorders.

.uicer.A lesion that forms in the wall of the stomach or of the duodenum.

+asthma®A medical problem marked by narrowing of the trachea and bron- chi, which results in shortness of breath, wheezing, coughing, and a choking sensation.

•insomnia•Difficulty falling or staying asleep.

. muscle contraction headache•A headache caused by a narrowing of muscles surrounding the skull. Also known as tension headache.

°migraine headache•A very severe headache that occurs on one side of the head, often preceded by a warning sen- sation and sometimes accompanied by dizziness, nausea, or vomiting.

Stress and the Psychological Stress Disorders

When we view a stressor as threatening, we often experience a stress response consisting of arousal and a sense of fear. The features of arousal and fear are set in motion by the hypothalamus, a brain area that activates the autonomic nervous system and the endocrine system. There are two pathways by which these sys- tems produce arousal and fear—the sympathetic nervous system pathway and the hypothalamic-pituitary-adrenal pathway.

People with acute stress disorder or posttraumatic stress disorder react with anxiety and related symptoms after a traumatic event, including reexperiencing the traumatic event and experiencing increased arousal, anxiety, and guilt. The symp- toms of acute stress disorder begin soon after the trauma and last less than a month, while those of posttraumatic stress disorder may begin of any time (even years) after the trauma and may last for months or years.

In attempting to explain why some people develop a psychological stress disorder, researchers have focused on biological factors, personality, childhood experiences, social support, multicultural factors, and the severity of the traumatic event. Treatments for the disorders include drug, exposure, insight, cognitive, family, and group therapy. Rapidly mobilized community therapy, which often follows the principles of critical incident stress debriefing, is frequently provided after large- scale disasters.

The Physical Stress Disorders: Psychophysiological Disorders As you have seen, stress can greatly affect our psychological functioning (see Figure 5-3). It can also have great impact on our physical fimctioning, contributing in some cases to the development of medical problems.The idea that stress and related psychosocial factors may contribute to physical illnesses has ancient roots, yet it had few supporters before the twentieth century.The belief began to take hold about 80 years ago, when clinicians first identified a group of physical illnesses that seemed to result from an interaction of biologi- cal, psychological, and sociocultural factors (Dunbar, 1948; Bott, 1928). Early editions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders, but DSM-IV-TR labels them psythological _Actors affecting medical condition (see Table 5 -2). The more familiar term "psychophysiological" will be used in this chapter.

It is important to recognize that psychophysiological disorders bring about actual physical damage. They are different from "apparent" physical illnesses—factitious disorders or somatofor• disorders—disorders that are accounted for entirely by psychological fac- tors such as hidden needs, repression, or reinforcement. Those kinds of problems will be examined in the next chapter.

Traditional Psychophysiological Disorders Before the 1970s, clinicians believed that only a limited number of illnesses were psy- chophysiological. 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 newer illnesses in 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 stain-

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Stress Disorders :1/ 1 49

ach bleeding.This disorder is experienced by 20 million people in the United States at some point during their lives and is responsible for more than 6,000 deaths each year. Ulcers are often caused by an interaction of stress factors, such as environmental pressure or intense feelings of anger or anxiety, and physiological factors, such as the bacteria H. pylori (Carr, 2001).

Asthma causes the body's airways (the trachea and bronchi) to narrow periodically, making it hard for air to pass to and from the luugs.The resulting symptoms are short- ness of breath, wheezing, coughing, and a terrifying choking sensation. Some 20 million people in the United States currently suffer from asthma, twice as many as 25 years ago (AAAAI, 2005). Most victims are children or young teenagers at the time of the first attack (Melamed et al, 2001). 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 (NCHS, 2005; Melamed et al., 2001).

Insomnia, difficulty falling asleep or maintaining sleep, plagues 35 percent of the population each year (Taylor, 2006). Although many of us have temporary bouts of in- somnia that last a few nights or so, a large number of people experience insomnia that lasts months or years. They feel as though they are almost constantly awake. Chronic insomniacs are often 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 (Thase, 2005;VandeCreek, 2005).

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. Approximately 40 million Americans suffer from such headaches. Migraine headaches are extremely severe, often near-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

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through them rapidly, stimulating many neuron endings and causing pain. Migraines are suffered by about 23 million people in the United States.

Research suggests that chronic headaches are caused by an interaction of stress fac- tors, such as environmental pressures or general feelings of helplessness, anger, anxiety, or depression, and physiological factors, such as abnormal activity of the neurotransmit- ter serotonin, vascular problems, or muscle weakness (Engel, 2009; Andrasik & Walch, 2003).

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 function- ing of the entire cardiovascular system, greatly increasing the likelihood of stroke, heart disease, and kidney problems. It is estimated that 65 million people in the United States have hypertension, 14,000 die directly from it annually, and millions more perish be- cause of illnesses caused by it (Kalb, 2004; Kluger, 2004). Around 10 percent of all cases are caused by physiological abnormalities alone; the rest result from a combination of psychosocial and physiological factors and are called essential hypertension (Sperry, 2009). 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 an individual's blood vessels (Taylor, 2006; Kluger, 2004).

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 it farction (a "heart attack"). Nearly 14 million people in the United States suffer from some form of coronary heart disease (AHA, 2005). It is the leading cause of death in men over the age of 35 and of women over 40 in the United States, accounting for close to 1 million deaths each year, around 40 percent of all deaths in the nation (Travis & Meltzer, 2008; AHA, 2005, 2003).The majority of all cases of coronary heart 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 a high level of cholesterol, obesity, hyperten- sion, smoking, or lack of exercise (Travis & Meltzer, 2008; Wang et al., 2004).

Over the years, clinicians have identified a number of variables that may generally contribute to the development of psychophysiological disorders (see Figure 5-4). It should not surprise us that several of these variables are the same as those that contribute to the onset of the psychological stress disorders—acute and posttraumatic stress disorders. The variables may be grouped as biological, psychological, and sociocultural factors.

Biological Factors You saw earlier 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

Siress Disorders :If 1 51

believed to contribute to the development of psychophysiological disorders (Hugdahl, 1995). 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 caus- ing a psychophysiological disorder (Boyce et al., 1995). 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.

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 experience a rise in blood pressure (Fahrenberg et al., 1995). Research has indicated, for example, that some individuals are particularly likely to experience temporary rises in blood pressure when stressed (Gianaros et al., 2005). It may be that they are prone to develop hypertension.

Consistent with these notions, a team of cardiologists at Johns Hopkins Medical In- stitutes offered an interesting report a few years ago on 19 patients who had symptoms of a severe heart attack (Wittstein et al., 2005). In fact, none of the patients had heart- tissue damage or clogged coronary arteries—that is, none had suffered a heart attack— but all had recently had a highly stressful experience and all displayed extraordinarily abnormal ANS and hormonal activity. Although such brain and bodily activity did not lead to an actual heart attack during that hospitalization, some of their cardiologists believed that repeated episodes could indeed contribute to coronary heart disease in the future (Akashi et al., 2004).

Psycholo2ical Factors According to many theorists, certain needs, attitudes, emo- tions, or coping styles may cause people to overreact repeatedly to stressors, and so in- crease their chances of developing psychophysiological disorders (Chung et al., 2005). Researchers have found, for example, that men with a repressive coping style (a reluctance to express discomfort, anger, or hostility) tend to experience a particularly sharp rise in blood pressure and heart rate when they are stressed (Pawls & Stemmler, 2003).

Another personality style that may contribute to psychophysiological disorders is the Type A personality style, an idea introduced by two cardiologists, Meyer Friedman and Raymond 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, in turn, are less likely to experience 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 eight 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 (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 and time urgency, may indeed be strongly related to heart disease (Myrtek, 2007; Taylor, 2006).

Sociocultural Factors: The Multicultural Perspective Adverse social con- ditions 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 relatively wealthy people have fewer psy- chophysiological disorders, better health, and better health outcomes than poor people (Matsumoto & Juang, 2008; Adler et al., 1994). One obvious reason for this relationship

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is that poorer people typically experience higher rates of crime, unemployment, over- crowding, and other negative stressors than wealthier people. In addition, they typically receive inferior medical care.

Research also reveals that belonging to ethnic and cultural minority groups increases the risk of developing psychophysiological disorders and other health problems (Travis & Meltzer, 2008).A major factor in this relationship may, once again, be economic.That is, many members of minority groups live in poverty and, in turn, experience the high rates of crime and unemployment and the inferior medical care that often result in poor health outcomes. Census data reveal, for example, that 70 percent of all people who have no health care insurance are Hispanic, African, or Asian American (U.S. Census Bureau, 2006). Moreover, women in these minority groups are particularly disadvantaged in the health care arena. Hispanic American women, for example, have the worst access to health care in the United States (Travis & Meltzer, 2008). Indeed, almost half of Hispanic American women who live in poverty have no health care insurance (Travis & Meltzer, 2008; Pamuk et al., 1998).

Research further suggests that the link between minority group status and psy- chophysiological disorders extends beyond economic factors. Consider, for example, the repeated finding that high blood pressure is 43 percent more common among African Americans than among white Americans (Kluger, 2004). Although this difference may be explained, in part, by the dangerous environments in which so many African Ameri- cans live and the unsatisfying jobs at which so many must work (Cozier-D'Amico, 2004), other factors may also be operating.A physiological predisposition among African Americans may, for example, increase their risk of developing high blood pressure. Or it may be that repeated experiences of racial discrimination constitute special stressors that help raise the blood pressure of African Americans (Matsumoto & Juang, 2008).

In one study, African American and white American women were instructed to talk about three hypothetical scenarios (Lepore et al., 2006). For one scenario, consid- ered a racial stressor, the research participants had to describe being unjustly accused of shoplifting. For another scenario, considered a nonracial stressor, they discussed being caught in airport delays. And, for the third scenario, which involved little or no stres- sors of any kind, the participants had to describe giving a campus tour. The African American participants displayed significantly greater rises in blood pressure than the white American participants when discussing the racial stressor scenario. Based on this finding, the experimenters concluded that perceptions of racism produce greater physi- ological stress for African American women, setting the stage for high blood pressure, other psychophysiological disorders, and generally poorer health.

New Psychophysiologica usorders Clearly, biological, psychological, and sociocultural factors combine to produce psy- chophysiological disorders. In fact, the interaction of such factors is now considered the rule of bodily functioning, not the exception, and, 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 first at how these links were established and then at psyclzoneu- roimmunology, the area of study that ties stress and illness to the body's immune system.

Are Physical Illnesses Related o Stress? In 1967 two researchers, Thomas Holmes and Richard Rahe, developed the Social Adjustment Rating Scale, which as- signs numerical values to the stresses that most people experience at some time in their lives (see Table 5-3). 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 mea- suring the total amount of stress a person faces over a period of time. If, for example, in the course of a year a woman started a new business (39 LCUs), sent her son off to college (29 LCUs), moved to a new house (20 LCUs), and experienced the death of a

Stress Disorders :1/ 153

Most Stressful Life Events

Adults: Social Adjustment Rating Scale*

1. Death of spouse

2. Divorce

14. Gain of new family member

15. Business readjustment

16. Change in financial state

17. Death of close friend

18. Change to different line of work

19. Change in number of arguments with spouse

20. Mortgage over $10,000

21. Foreclosure of mortgage or loan

22. Change in responsibilities at work

3. Marital separation

4. Jail term

5. Death of close family member

6. Personal injury or illness

7. Marriage

8. Fired at work

9. Marital reconciliation

10. Retirement

11. Change in health of family member

12. Pregnancy

13. Sex d ifficulties

*Full scale has 43 items. Source: Holmes & Rabe, 1967.

Students: Undergraduate Stress Questionnaire

1. Death (family member or friend)

2. Had a lot of tests

3. It's finals week

4. Applying to graduate school

5. Victim of a crime

6. Assignments in all classes due the same day

7. Breaking up with boy-/girlfriend

8. Found out boy-/girlfriend cheated on you

9. Lots of deadlines to meet

10. Property stolen

11. You have a hard upcoming week

12. Went into a test unprepared

13. Lost something (especially wallet)

14. Death of a pet

15. Did worse than expected on test

17. Had projects, research papers due

18. Did badly on a test

19. Parents getting divorce

20. Dependent on other people

21. Having roommate conflicts

22. Car/bike broke down, flat tire, etc.

Tull scale has 83 items. Source: Crandall et al., 1992.

close friend (37 LCUs), her stress score for the year would be 125 LCUs, a considerable amount of stress for such a period of time.

With this scale in hand, Holmes and Rahe (1989, 1967) were able to examine the relationship between life stress and the onset of illness.They found that the LCU scores of sick people during the year before they fell ill were much higher than those of healthy people. If a person's life changes totaled more than 300 LCUs over the course of a year, that person was particularly likely to develop a serious health problem.

Using the Social Adjustment Rating Scale or similar scales, studies have since linked stresses of various kinds to a wide range of physical conditions, from trench mouth and upper respiratory infection to cancer (Cohen, 2005; Taylor, 2004). Overall, the greater the amount of life stress, the greater the likelihood of illness (see Figure 5-5 on the next page). Researchers even have found a relationship between traumatic stress and death. Widows and widowers, for example, display an increased risk of death during their period of bereavement (Rees & Lutkin, 1967;Young et al., 1963).

One shortcoming of Holmes and Rahe's Social Adjustment Rating Scale is that it does not take into consideration the particular life stress reactions of specific popula- tions. For example, in their development of the scale, the researchers sampled white

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1 54 :figNARTER 5

Americans predominantly. Few of the respondents were African Americans. But since their ongoing life experiences often differ in key ways, might not African Americans and white Americans differ in their stress reactions to various kinds of life events? One study indicates that indeed they do (Komaroff et al., 1989, 1986). Although both white Americans and African Americans rank death of a spouse as the single most stressful life event, African Americans experience greater stress than white Americans in response to a major personal injury or illness, a major change in work responsibilities, or a major change in living conditions. Similarly, studies have shown that women and men differ in their reactions to certain life changes (Miller & Rahe, 1997).

Finally, college students may face stressors that are different from those listed in the Social Adjustment Rating Scale. Instead of having marital difficulties, being fired, or applying for a job, a college student may have trouble with a roommate, fail a course, or apply to graduate school. When researchers developed special scales to measure life events more accurately in this population (see Table 5-3 again), they found the expected relationships between stressful events and illness (Crandall et al., 1992).

Psychoneuroimmunology How do stressful events result in a viral or bac- terial infection? An area of study called psychoneuroimmunology seeks to answer this question by uncovering the links between psychosocial stress, the im- mune system, and health.

The immune system is the body's network of activities and cells that identify and destroy antigens—foreign invaders, such as bacteria, viruses, fungi, and parasites—and cancer cells. Among the most important cells in this system are billions of lympho- cytes, white blood cells that circulate through the lymph system and the bloodstream. When stimulated by antigens, lymphocytes spring into action to help the body over- come the invaders.

One group of lymphocytes, called helper T-cells, identifies antigens and then multi- plies and triggers the production of other kinds of immune cells. Another group, natural hillerT-cells, seeks out and destroys body cells that have already been infected by viruses, thus helping to stop the spread of a viral infection.A third group of lymphocytes, B -cells, produces antibodies, protein molecules that recognize and bind to antigens, mark them for destruction, and prevent them from causing infection.

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•psyclrioneuroimmunology•The study of the connections between stress, the body's immune system, and illness.

•immune system•The body's network of activities and cells that identify and destroy antigens and cancer cells.

•antigen•A foreign invader of the body, such as a bacterium or virus.

•Iymphocytes•White blood cells that circulate through the lymph system and bloodstream, helping the body identify and destroy antigens and cancer cells.

Stress Disorders :1/ 1 55

Researchers now believe that stress can interfere with the activity of lymphocytes, slowing them down and thus increasing a person's susceptibility to viral and bacterial infections (Lutgendorf et al., 2005). In a landmark study, investigator Roger Bartrop and his colleagues (1977) in New South Wales, Australia, compared the immune systems of 26 people whose spouses had died eight weeks earlier with those of 26 matched control group participants whose spouses had not died. Blood samples revealed that lymphocyte functioning was much lower in the bereaved people than in the controls. Still other studies have shown slow immune functioning in persons who are exposed to long-term stress. For example, researchers have found poorer immune functioning among people who face the challenge of providing ongoing care for a relative with Alzheimer's disease (Vitaliano et al., 2005; Kiecolt-Glaser et al., 2002, 1996).

These studies seem to be telling a remarkable story. During periods when healthy individuals happened to experience unusual levels of stress, they remained healthy on the surface, but their experiences apparently slowed their immune systems so that they became susceptible to illness. If stress affects our capacity to fight off illness, it is no won- der that researchers have repeatedly found a relationship between life stress and illnesses of various kinds. But why and when does stress interfere with the immune system? Sev- eral factors influence whether stress will result in a slowdown of the system, including biochemical activity, behavioral changes, personality style, and degree of social support.

BIOCHEMICAL ACTIVITY Excessive activity of the neurotransmitter norepinephrine apparently contributes to slowdowns of the immune system. Remember that stress leads to increased activity by the sympathetic nervous system, including an increase in the release of nor- epinephrine throughout the brain and body. Research indicates that if stress continues for an extended time, norepinephrine eventually travels to receptors on certain lymphocytes and gives them an inhibitory message to stop their activity, thus slowing down immune functioning (Carlson, 2008; Lekander, 2002).

In a similar manner, corticosteroids— cortisol and other so-called stress hormones-- apparently contribute to poorer immune system functioning. Remember that when a person is under stress, the adrenal glands release corticosteroids. As in the case of nor- epinephrine, if stress continues for an extended time, the stress hormones eventually travel to receptor sites located on certain lymphocytes and give an inhibitory message, again causing a slowdown of the activity of the lymphocytes (Bauer, 2005; Bellinger et al., 1994) .

Recent research has further indicated that another action of the corticosteroids is to trigger an increase in the production of cytokines, proteins that bind to receptors throughout the body. At moderate levels of stress, the cytokines, another key player in the immune system, help combat infection. But as stress continues and more corti- costeroids are released, the growing production and spread of cytokines lead to chronic inflammation throughout the body, contributing at times to heart disease, stroke, and other illnesses (Travis & Meltzer, 2008; Suarez, 2004).

BEHAVIORAL CHANGES Stress may set in motion a series of behavioral changes that indi- rectly affect the immune system. Some people under stress may, for example, become anxious or depressed, perhaps even develop an anxiety or mood disorder.As a result, they may sleep badly, eat poorly, exercise less, or smoke or drink more—behaviors known to slow down the immune system (Irwin & Cole, 2005).

PERSONALITY STYLE According to research, people who generally respond to life stress with optimism, constructive coping, and resilience—that is, people who welcome challenges and are willing to take control in their daily encounters—experience better immune system functioning and are better prepared to fight off illness (Taylor, 2006, 2004). Some studies find, for example, that people with "hardy" or resilient personalities remain healthy after stressful events, while those whose personalities are less hardy seem more susceptible to illness (Bonanno, 2004; Ouellette & DiPlacido, 2001). One study even discovered that men with a general sense of hopelessness die at above-average rates from heart disease and other causes (Everson et al., 1996). Similarly, a growing body of research suggests that people who are spiritual tend to be healthier than individuals

156 :IICHAPTER 5

without spiritual beliefs, and a few studies have linked spirituality to better im- mune system functioning (Thoresen & Plante, 2005; Lutgendorf et al., 2004).

In related work, certain studies have noted a relationship between certain personality characteristics and recovery from cancer (Hjerl et al., 2003). They have found that patients with certain forms of cancer who display a helpless coping style and who cannot easily express their feelings, particularly anger, tend to have less successful recoveries than patients who do express their emo- tions. Other studies, however, have found no relationship between personality and cancer outcome (Urcuyo et al., 2005; Garssen & Goodkin, 1999).

SOCIAL SUPPORT Finally, 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 (Curtis et al., 2004; Cohen, 2002). In a pioneering study, medical students were given the UCLA Loneliness Scale and then divided into "high" and "low" loneliness groups (Kiecolt-Glaser et al., 1984).The high-loneliness group showed lower lymphocyte responses during a final exam period.

Other studies have found that social support and affiliation may actually help protect people from stress, poor immune system functioning, and subse- quent illness or help speed up recovery from illness or surgery (Matsumoto & juang, 2008; Taylor, 2006). Similarly, some studies have suggested that patients with certain forms of cancer who receive social support in their personal lives or supportive therapy often have better immune system functioning and, in turn, more successful recoveries than patients without such supports (Taylor, 2006; Spiegel & Fawzy, 2002).

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'behavioral medicine' A field that combines psychological and physical interventions to treat or prevent medical problems.

Psychological Treatments for Physical Disorders As clinicians have discovered that stress and related psychosocial factors may contribute to physical disorders, they have applied psychological treatments to more and more medical problems. The most common of these interventions are relaxation training, biofeedback, meditation, hypnosis, cognitive interven- tions, insight therapy, and support groups.The field of treatment that combines psychological and physical approaches to treat or prevent medical problems is

known as behavioral medicine.

Relaxation Training As you saw in Chapter 4, people can be taught to relax their muscles at will, a process that sometimes reduces feelings of anxiety. Given the positive effects of relaxation on anxiety and the nervous system, clinicians believe that relaxation training can help prevent or treat medical illnesses that are related to stress.

Relaxation training, often in combination with medication, has been widely used in the treatment of high blood pressure (Stetter & Kupper, 2002). It has also been of some help in treating headaches, insomnia, asthma, diabetes, pain after surgery, certain vascular diseases, and the undesirable effects of certain cancer treatments (Devineni & Blanchard, 2005; Carmichael, 2004).

iofeedback. As you also saw in Chapter 4, patients given biofeedback training are con- nected to machinery that gives them continuous readings about their involuntary body activities. This information enables them gradually to gain control over those activities. Somewhat helpful in the treatment of anxiety disorders, the procedure has also been ap- plied to a growing number of physical disorders.

In a classic study, electromyograph (EMG) feedback was used to treat 16 patients who were experiencing facial pain caused in part by tension in their jaw muscles (Dohrmann & Laskin, 1978). In an EMG procedure, electrodes are attached to a person's muscles so that the muscle contractions are detected and converted into a tone for the individual to hear (see pages 105-106). Changes in the pitch and volume of the tone indicate changes in muscle tension. After "listening" to EMG feedback repeatedly, the 16 patients in this study learned how to relax their jaw muscles at will and later reported a reduction in facial pain.

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EMG feedback has also been used successfully in the treatment of headaches and muscular disabilities caused by strokes or accidents. Still other forms of biofeedback training have been of some help in the treatment of heartbeat irregu- larities, asthma, migraine headaches, high blood pressure, stut- tering, and pain (Martin, 2002; Moss, 2002; Gatchel, 2001).

MeditatiOri Although meditation has been practiced since ancient times,Western health care professionals have only re- cently become aware of its effectiveness in relieving physical distress. Meditation is a technique of turning one's concen- tration inward, achieving a slightly changed state of con- sciousness, and temporarily ignoring all stressors. In the most common approach, meditators go to a quiet place, assume a comfortable posture, utter or think a particular sound (called a mantra) to help focus their attention, and allow their minds to turn away from all outside thoughts and concerns (Dass & Levine, 2002). Many people who meditate regularly report feeling more peaceful, engaged, and creative. Meditation has been used to help manage pain and to treat high blood pres- sure, heart problems, asthma, skin disorders, diabetes, insomnia, and even viral infections (Stein, 2003 ;Andresen, 2000).

One form of meditation that has been applied in particular to patients suffering from severe pain is mindfulness meditation (Carey, 2008; Kabat-Zinn, 2005). Here meditators pay attention to the feelings, thoughts, and sensations that are flowing through their minds during meditation, but they do so with detachment and objectivity and, most importantly, without judgment. By just being mindful but not judgmental of their feel- ings and thoughts, including feelings of pain, they are less inclined to label them, fixate on them, or react negatively to them.

Hyp110515 As you saw in Chapter 1, individuals who undergo hypnosis are guided by a hypnotist into a sleeplike, suggestible state during which they can be directed to act in unusual ways, experience unusual sensations, remember seemingly forgotten events, or forget remembered events.With training some people are even able to induce their own hypnotic state (self-hypnosis). Hypnosis is now used as an aid to psychotherapy and to help treat many physical conditions (Shenefelt, 2003).

Hypnosis seems to be particularly helpful in the control of pain (Kiecolt-Glaser et al., 1998). One case study describes a patient who underwent dental surgery under hypnotic suggestion: After a hypnotic state was induced, the dentist suggested to the patient that he was in a pleasant and relaxed setting listening to a friend describe his own success at undergoing similar dental surgery under hypnosis. The dentist then proceeded to per- form a successful 25-minute operation (Gheorghiu & Orleanu, 1982). Although only some people are able to undergo surgery while anesthetized by hypnosis alone, hypnosis combined with chemical forms of anesthesia is apparently helpful to many patients (Fredericks, 2001). Beyond its use in the control of pain, hypnosis has been used success- fully to help treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and other forms of infection (Modlin, 2002; Hornyak & Green, 2000).

Cognitive interventions People with physical ailments have sometimes been taught new attitudes or cognitive responses toward their ailments as part of treatment (Kyrios, 2009; Devineni & Blanchard, 2005). For example, an approach called self- instruction train- ing has helped patients cope with severe pain (Allison & Friedman, 2004; Meichenbaum, 1997, 1993, 1977, 1975). In self-instruction training therapists teach people to identify and eventually rid themselves of unpleasant thoughts that keep emerging during pain episodes (so -called negative selfLstatements, such as "Oh, no, I can't take this pain") and to replace them with coping self-statements instead (for example, "When pain comes, just pause; keep focusing on what you have to do").

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insight Therapy and Support Groups If anxiety, depression, anger, and the like contribute to a person's physical ills, therapy to reduce these nega- tive emotions should help reduce the ills. In such cases, physicians may rec- ommend insight therapy, support groups, or both to help patients overcome their medical difficulties (Antoni, 2005). Research suggests that the discus- sion of past and present upsets may indeed help improve a person's health, just as it may help one's psychological functioning (Leibowitz, 2007; Smyth & Pennebaker, 2001). In one study, asthma and arthritis patients who simply wrote down their thoughts and feelings about stressful events for a handful of days showed lasting improvements in their conditions. Similarly, stress-related writing was found to be beneficial for patients with HIV infections (Petrie et al., 2004). In addition, as we have seen, recovery from cancer and certain other illnesses is sometimes improved by participation in support groups (Antoni, 2005; Spiegel & Fawzy, 2002).

Combination Approaches Studies have found that the various psy- chological interventions for physical problems tend to be equal in effective- ness (Devineni & Blanchard, 2005). Relaxation and biofeedback training, for

example, are equally helpful (and more helpful than placebos) in the treatment of high blood pressure, headaches, and asthma. Psychological interventions are, in fact, often of greatest help when they are combined with other psychological interventions and with medical treatments (Suinn, 2001). In one study, ulcer patients who were given relax- ation, self-instruction, and assertiveness training along with medication were found to be less anxious and more comfortable, have fewer symptoms, and have a better long-term outcome than patients who received medication only (Brooks & Richardson, 1980). Combination interventions have also been helpful in changing Type A patterns and in reducing the risk of coronary heart disease among Type A people (Williams, 2001; Cohen et al., 1997).

Clearly, the treatment picture for physical illnesses has been changing dramatically. While medical treatments continue to dominate, today's medical practitioners are travel- ing a course far removed from that of their counterparts in centuries past.

• JM i LP The Physical Stress Disorders

Psychophysiological disorders are those in which psychosocial and physiological factors interact to cause a physical problem. Variables linked to these disorders are biological factors, such as defects in the autonomic nervous system; psychological factors, such as particular needs, attitudes, or personality styles; and sociocultural factors, such as negative social conditions and cultural pressures.

For years clinical researchers singled out a limited number of physical illnesses as psychophysiological, such as ulcers, asthma, and coronary heart disease. Re- cently many other psychophysiological disorders have been identified. Scientists hove developed an area of study called psychoneuroimmunology, which links many physical illnesses to stress and immune system functioning. Stress can slow lympho- cyte and other immune system activity, thereby interfering with the system's ability to protect against illness. Factors that seem to affect immune functioning include norepinephrine and corticosteroid activity, behavioral changes, personality style, and social support.

Behavioral medicine combines psychological and physical interventions to treat or prevent medical problems. Psychological approaches such as relaxation training, biofeedback training, meditation, hypnosis, cognitive techniques, insight therapy, and support groups are increasingly being included in the treatment of various medical problems.

Stress Disorders :1/ 1 59

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Empathy Goes a Long Way

BY DENISE GRADY, NEW YORK TIMES, JANUARY 8, 2008

our years ago, my sister found out she had two types of cancer at the same time. It was like being hit by

lightning —twice. She needed chemotherapy and radiation, a huge operation,

more chemotherapy and then a smaller operation. All in all, the treatment took about a year. Thin to begin with, she lost 30 pounds. The chemo caused cracks in her fingers, dry eyes, anemia and mouth sores so painful they kept her awake at night. A lot of her hair fell out. The radiation burned her skin. . . .

She saw two doctors quite often. The radiation oncologist would sling her arm around my sister's frail shoul- ders and walk her down the corridor as if they were old friends. The medi- cal oncologist kept a close watch on the side effects, suggested remedies, reminded my sister she had good odds of beating the cancer and reassured her that the hair would grow back. (It did.)

People in my family aren't huggy-kissy types, but my sister greatly appreciated the warmth and concern of those two women. She trusted them completely, and their advice. Now healthy, she says their compassion played a big part in helping her get through a difficult and frightening time.

Research supports the idea that a few kind words from an oncologist—what used to be called bedside manner—can go a long way toward helping people with cancer understand their treatment, stick with it, cope better and maybe even fare better medically. "It is absolutely the role of the oncologist" to provide a bit of emotional support, said Dr. James A. Tulsky, director of the Center for Palliative Care at Duke University Medical Center.

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But in a study published last month in the Journal of Clinical Oncology, Dr. Tulsky and other researchers found that doctors and patients weren't communicating all that well about emo- tions. The researchers recorded 398 conversations between 51 oncologists and 270 patients with advanced cancer. They listened for moments when patients expressed negative emotions like fear, anger or sadness, and for the doctors' replies.

A response like "I can imagine how scary this must be for you" was considered empathetic—a "continuer" that would allow patients to keep expressing their emotions. But a comment like "Give us time; we are getting there" was labeled a "terminator" that could shut the patient down. The team found that doctors used continuers only 22 per- cent of the time. Male doctors were worse at it than female ones: 48 percent of the men never used con- tinuers, as opposed to 20 percent

of the women.... Dr. Tulsky said, "There were a number of times when patients brought up emotional content and it went right by the doctors." For instance, a patient would say, "I'm scared," and the doctor would go off on a "scientific riff" about the disease. . . .

The good news ... is that most doctors can be taught to re- spond in more helpful ways. Brief, empathetic responses will suf- fice, the researchers said; they are not recommending extensive counseling or endless dialogue. Patients may benefit from some coaching, too. It's perfectly reasonable, Dr. Tulsky said, to talk to an oncologist about sadness or fears about treatment, and to ask for help.

Copyright (0 2008 New York Times. All rights reserved. Used by permission. !:

PUTTING T. together Expanding the Boundaries of Abnormal Psychology

The concept of stress is familiar to everyone, yet only in recent decades have clinical scientists and practitioners had much success in understanding and treating it and recog- nizing its powerful impact on our functioning. Now that the impact of stress has been identified, however, research efforts in this area are moving forward at near-lightning speed.What researchers once saw as a vague connection between stress and psychologi- cal dysfunctioning or between stress and physical illness is now understood as a complex interaction of many variables. Such factors as life changes, individual psychological states,

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160 ://CHAPTER 5

social support, biochemical activity, and slowing of the immune system are all recog- nized as contributors to psychological and physical stress disorders.

Insights into the treatment of the various stress disorders have been accumulating just as rapidly. In recent years clinicians have learned that a combination of approaches— from drug therapy to behavioral techniques to community interventions—may be of help to people with acute and posttraumatic stress disorders. Similarly, psychological approaches such as relaxation training and cognitive therapy are being applied to various physical ills, usually in combination with traditional medical treatments. Small wonder that many practitioners are convinced that such treatment combinations will eventually be the norm in treating the majority of physical ailments.

One of the most exciting aspects of these recent developments is the field's grow- ing emphasis on the interrelationship of the social environment, the brain, and the rest of the body. Researchers have observed repeatedly that mental disorders are often best understood and treated when sociocultural, psychological, and biological factors are all taken into consideration.They now know that this interaction also helps explain medi- cal problems. We are reminded that the brain is part of the body and that both are part of a social context. For better and for worse, the three are closely linked.

Another exciting aspect of this work on stress and its wide-ranging impact is the interest it has sparked in illness prevention and health promotion (Compas & Gotlib, 2002; Kaplan, 2000). If stress is indeed key to the development of both psychological and physical disorders, perhaps such disorders can be prevented by eliminating or reducing stress—for example, by helping people to cope better generally or by better preparing their bodies for stress's impact. With this notion in mind, illness prevention and health promotion programs are now being developed around the world. Clinical theorists have, for example, designed school-curriculum programs to help promote social competence in children (Weissberg, 2000) and to teach children more optimistic ways of thinking (Gillham et al., 2000, 1995).And in the realm of acute and posttraumatic stress disorders, one team of clinical researchers has developed a program that immediately offers rape victims a combi- nation of relaxation training, exposure techniques, cognitive interventions, and education about rape's impact, all before the onset of psychological or physical symptoms (Muran, 2007; Foa et al., 2005, 1995). Research indicates that women who receive such preventive measures do indeed develop fewer stress symptoms than do other rape victims.

\\\ THOUrTHTS/// What types of events in modern society might trigger acute and post- traumatic stress disorders? What kinds of factors might serve to relieve the stresses of modern society? pp. 137- 148

Do you think the vivid images seen daily on the Web, on television, in movies, in rock videos, and the like would make people more vulnerable

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to developing psychological stress disorders or less vulnerable? Why? pp. 137-144

3. How might physicians, police, the courts, and other agents better meet the psychological needs of rape victims? pp. 138- 140

4. To help fend off terrorism attacks, the United States and other countries

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have instituted various procedures, such as color-coded (threat-level) warning systems. How might such warning systems affect the psycholog- ical and physical health of citizens? pp. 140, 141

5. What jobs in our society might be particularly stressful and traumatiz- ing? pp. 148-150, 152-154

• • •

endocrine system, p. 135

epinephrine, p. 135

norepinephrine, p. 135

hypothalamic-pituitary-adrenal (HPA) pathway, p. 136

corticosteroids, p. 136

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el; acute stress disorder, p. 136 rape, p. 138

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ulcer, p. 148

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posttrctumatic stress disorder (PTSD), p. 136

insomnia, p. 149

headaches, p. 149

hypertension, p. 150

coronary heart disease, p. 150 Type A personality style, p. 151

Social Adjustment Rating Scale, p. 152

psychoneuroimmuology, p. 154

immune system, p. 154

antigen, p. 154

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lymphocyte, p. 154

cytokines, p. 155

behavioral medicine, p. 156

relaxation training, p. 156

biofeedback training, p. 156

meditation, p. 157

hypnosis, p. 157

self-instruction training, p. 157

\\\r)uriK ')U12/// ,A; yzi 1. What factors determine how

people react to stressors in life? pp. 134-136

V::: 2. What factors seem to help influence whether a person will develop a psychological stress disorder after experiencing a traumatic event? pp. 142-144

3.

aches, hypertension, and coronary heart disease? pp. 148- 150

5. What kinds of biological, psycho. logical, and sociocultural factors appear to contribute to psychophys- iological disorders? pp. 151 - 152

6. What kinds of links have been found between life stress and physical illnesses? What scale has helped researchers investigate this relationship? pp. 152- 154

7. Describe the relationship among stress, the immune system, and physical illness. pp. 154-156

8. Explain the specific roles played by various types of lymphocytes. pp. 154- 155

9. Discuss how immune system func- tioning at times of stress may be affected by a person's biochemical activity, behavioral changes, per- sonality style, and social support. pp. 155- 156

1 O. What psychological treatments have been used to help treat physi- cal illnesses? To which specific illnesses has each been applied? pp. 156-158

What treatment approaches have been used with people suffering from acute or posttraumatic stress disorders? pp. 144- 147

4. What are the specific causes of 0•

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Search the Fundamentals of Abnormal Psychology Video Tool Kit www.worthpublishers.com/apvtk

A Chapter 5 Video Cases Fight-or-Flight: How Stress Affects Psychological and Bodily Functioning One Man's Return from Combat Caretaking: The Physical Toll

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SOMATOFORM AND DISSOCIATIVE DISORDERS CHAPTER

rian 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. After 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.

After 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 ... conversations with friends . . . self-blame . grief . and more.

Compounding this horror, the accident had left 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 after 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 lift him to a chair, and after he told his story and the authorities were alerted, he had to be taken to a hospital.

At first Brian and the hospital physician assumed that he must have been hurt during the ac- cident. 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. Someone else had to inform Helen's parents or her death. 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 fife. Almost from the beginning, Brian's paralysis had left him self-absorbed and drained of emotion, unable to look back and unable to move forward.

In the previous two chapters you saw how stress and anxiety can negatively affect functioning. Indeed, anxiety is the key feature of disorders such as generalized anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder. And stress can produce the lingering reactions seen in acute stress disorder, posttrau- matic stress disorder, and psychophysiological disorders.

Two other kinds of disorders are commonly linked to stress and anxiety- somatofor -m disorders and dissociative disorders. Somatoform disorders are problems that appear to be medical but are actually caused by psychosocial factors. Unlike

TOPIC OVERVIEW Somatoform Disorders Conversion Disorder Somatization Disorder

Pain Disorder Associated with Psychological Factors

Hypochondriasis

Body Dysmorphic Disorder

What Causes Somatoform Disorders?

How Are Somatoform Disorders Treated?

Dissociative Disorders

Dissociative Amnesia

Dissociative Fugue

Dissociative Identity Disorder (Multiple Personality Disorder)

How Do Theorists Explain Dissociative Disorders?

How Are Dissociative Disorders Treated?

Putting It Together: Disorders Rediscovered

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psychophysiological disorders, in which psychosocial factors interact with genuine physical ailments, the somatoform dis- orders are psychological disorders masquerading as physical problems. Similarly, dissociative disorders are patterns of memory loss and identity change that are caused almost entirely by psychosocial factors rather than physical ones.

The somatoform and dissociative disorders have much in common. Both, for example, may occur in response to severe stress, and both have traditionally been viewed as forms of es- cape from that stress. In addition, a number of individuals suffer from both a somatoform and a dissociative disorder (Brown et al., 2007). Indeed, theorists and clinicians often explain and treat the two groups of disorders in similar ways.

•Somatoform Disorders Think back to Brian, the young man whose tragic boating ac- cident left him unable to walk. As medical test after test failed to explain his paralysis, physicians became convinced that the cause of his problem lay elsewhere.

When a physical ailment has no apparent medical cause, doctors may suspect a somatoform disorder, a pattern of physical complaints with largely psychosocial causes. People with such disorders do not consciously want or purposely produce their symptoms; like Brian, they almost always believe that their problems are genuinely medical (Phillips, Fallon, & King, 2008). In some somatoform disorders, known as hysterical somatoform disorders, there is an actual change in physical functioning. In others, the preoccupation somatoform disorders, people who are healthy mistakenly worry that there is something physically wrong with them.

What Are Hysterical Somatoform Disorders? People with hysterical somatoform disorders suffer actual changes in their physical functioning. These somatoform disorders are often hard to distinguish from genuine medical problems (Phillips et al., 2008). In fact, it is always possible that a diagnosis of hysterical disorder is a mistake and that the patient's problem has an undetected organic cause (Aybek et al., 2008; Merskey, 2004). DSM-IV-TR lists three hysterical somato- form disorders: conversion disordel; somatization disorder; and pain disorder associated with psychological factors.

Conversion Disorder In conversion disorder, a psychosocial conflict or need is converted into dramatic physical symptoms that affect voluntary motor or sensory func- tioning (see Table 6-1). Brian, the man with the unexplained paralysis, would probably receive this particular diagnosis.The symptoms often seem neurological, such as paralysis, blindness, or loss of feeling (APA, 2000). One woman developed dizziness in apparent response to her unhappy marriage:

A 46-year-old married housewife . . . described being overcome with feelings of ex- treme dizziness, accompanied by slight nausea, four or five nights a week. During these attacks, the room around her would take on a "shimmering" appearance, and she would have the feeling that she was "floating" and unable to keep her balance. Inexplicably, the attacks almost always occurred at about 4:00 P.M. She usually had to fie down on the couch and often did not feel better until 7:00 or 8:00 P.M. After recovering, she generally spent the rest of the evening watching TV; and more often than not, she would fall asleep in the living room, not going to bed in the bedroom until 2:00 or 3:00 in the morning.

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The patient had been pronounced physically fit by her internist, a neurologist, and an ear, nose, and throat specialist on more than one occasion. Hypoglycemia had been ruled out by glucose tolerance tests.

When asked about her marriage, the patient described her husband as a tyrant, fre- quently demanding and verbally abusive of her and their four children. She admitted that she dreaded his arrival home from work each day, knowing that he would comment that the house was a mess and the dinner, if prepared, not to his liking. Recently, since the onset of her attacks, when she was unable to make dinner he and the four kids would go to McDona Id's or the local pizza parlor. After that, he would settle in to watch a ballgame in the bedroom, and their conversation was minimal. In spite of their troubles, the patient claimed that she loved her husband and needed him very much.

(Spitzer et al., 1981, pp. 92-93)

Most conversion disorders begin between late childhood and young adulthood; they

are diagnosed at least twice as often in women as in men (Abbey, 2005; APA, 2000). They usually appear suddenly, at times of extreme stress, and last a matter of weeks. Some research suggests that people who develop this disorder tend to be generally suggestible; many are highly susceptible to hypnotic procedures, for example (Roelofs et al., 2002). Conversion disorders are thought to be quite rare, occurring in at most 5 of every 1,000 persons.

osomatoform disorderoA physical ill- ness or ailment that is explained largely by psychosocial causes, in which the patient experiences no sense of wanting or guiding the symptoms.

°hysterical somatoform disorders° Somatoform disorders in which people suffer actual changes in their physical functioning.

°conversion disorderoA somatoform disorder in which a psychosocial need or conflict is converted into dramatic physical symptoms that affect voluntary motor or sensory function.

osomatization disorder®A somatoform disorder marked by numerous recurring physical ailments without an organic basis. Also known as Briquet's syndrome.

*pain disorder associated with psychological factors°A sornatoform disorder marked by pain, with psycho- social factors playing a central role in the onset, severity, or continuation of the pain.

°factitious disorderoAn illness with no identifiable physical cause, in which the patient is believed to be intentionally producing or faking symptoms in order to assume a sick role.

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

Sheila reported having abdominal pain since age I 7, necessitating exploratory surgery that

yielded no specific diagnosis. She had several pregnancies, each with severe nausea, vomit-

ing, 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 Hotel hernia because of complaints of bloating 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., 1981, pp. 185, 260)

1 66 ://CHAPTER 6

Like Sheila, people with somatization disorder have many long-lasting physical ailments that have little or no organic basis (see again Table 6-1). This hysterical pat- tern, first described by Pierre Briquet in 1859, is also known as Briquet's syndrome. To receive this diagnosis, a person must have a range of ailments, including several pain symptoms (such as headaches and chest pain), gastrointestinal symptoms (such as nausea and diarrhea), a sexual symptom (such as erectile or menstrual difficulties), and a neurological symptom (such as double vision or paralysis) (APA, 2000). People with somatization disorder usually go from doctor to doctor in search of relief. They often describe their many symptoms in dramatic and exaggerated terms. Most also feel anx- ious and depressed (Creed, 2009; Fink et al., 2004; APA, 2000).

Between 0.2 and 2.0 percent of all women in the United States may experience a somatization disorder in any given year, compared to less than 0.2 percent of men (North, 2005;APA, 2000).The disorder often runs in families; as many as 20 percent of the close female relatives of women with the disorder also develop it. It usually begins between adolescence and young adulthood.

A somatization disorder lasts much longer than a conversion disorder, typically for many years (Yutzy, 2007). The symptoms may fluctuate over time but rarely disappear

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completely -without therapy (Abbey, 2005). Two-thirds of individuals with this disorder in the United States receive treatment for their physical ailments from a medical or mental health professional in any given year (Regier et al., 1993).

Pain Disorder Associated with Psychological Factors When psychosocial factors play a central role in the onset, severity, or continuation of pain, patients may re- ceive a diagnosis of pain disorder associated with psychological factors (see again Table 6-1). Patients with a conversion or somatization disorder may also experience pain, but it is the key symptom in this disorder.

Although the precise prevalence has not been determined, pain disorder associated with psychological factors appears to be fairly common (Creed, 2009).The disorder may begin at any age, and women seem more likely than men to experience it (APA, 2000). Often it develops after an accident or during an illness that has caused genuine pain, which then takes on a life of its own. 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. After 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 after 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)

Hysterical vs. Medical Symptoms Because hysterical somatoform disorders are so similar to "genuine" medical ailments, physicians sometimes rely on oddities in the patient's medical picture to help distinguish the two (Phillips et al., 2008; Kirmayer & Looper, 2007). The symptoms of a hysterical disorder may, for example, be at odds with the way the ner- vous system is known to work (APA, 2000). In a conversion symptom called glove anesthesia, numbness begins sharply at the wrist and extends evenly right to the fingertips. As Figure 6-1 shows, real neurological damage is rarely as abrupt or evenly spread out.

The physical effects of a hysterical disorder may also differ from those of the cor- responding medical problem. 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. People whose paralysis is the result of a conversion disorder, in contrast, do not usually experience atrophy. Perhaps they exercise their muscles without being aware that they are doing so. Similarly, people with conver- sion 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.

Hysterical VS, Factitious Symptoms Hysterical somatoform disorders are dif- ferent from patterns in which individuals are purposefully producing or faking medical symptoms.A patient may, for example,inatinget—intentionally fake illness to achieve some external gain, such as financial compensation (Phillips et al., 2008). Or a patient may in- tentionally produce or fake physical symptoms simply out of a wish to be a patient; that is, the motivation for assuming the sick role may be the role itself. Physicians would then decide that the patient is displaying a factitious disorder.

168 I/CHAPTER 6

People with a factitious disorder often go to extremes to create the appearance of ill- ness (Phillips et al., 2008). Many give themselves medications secretly. Some inject drugs to cause bleeding. High fevers are especially easy to create. In one study of patients with long-standing mysterious fever, more than 9 percent were eventually diagnosed with facti- tious disorder (Feldman, Ford, & Reinhold, 1994). People with a factitious disorder often research their supposed ailments and are impressively knowledgeable about medicine.

Psychotherapists and medical practitioners often become angry at people with a factitious disorder, feeling that these individuals are, among other issues, wasting their time.Yet people with this disorder, like most persons with psychological disorders, feel they have no control over their problem, and they often experience great distress.

Munchausen syndrome is the extreme and long-term form of factitious disor- der. It is named after Baron Munchausen, an eighteenth-century cavalry officer who

A CLO$ER LOOK

Munchausen Syndrome by Proxy

[Jennifer] had been hospitalized 200 times and under- gone 40 operations. Physicians removed her gallbladder, her appendix and part of her intestines, and inserted tubes into her chest stomach and intestines. [The 9-year-old from Florida] was befriended by the Florida Marlins and served as a poster child for health care reform, posing with Hillary Rodham Clinton at a White Rouse rally. Then police notified her mother that she was under investigation for child abuse. Suddenly, Jennifer's condition improved dramatically In the next nine months, she was hospitalized only once, for a viral infection. . . . Experts said Jennifer's numerous baffling infections were "consistent with someone smearing fecal matter" into her feeding line and urinary catheter.

(KATEL& BECK, 1996)

ases like Jennifer's have horrified i the public and called attention to

Munchausen syndrome by proxy. This dis- order is caused by a caregiver who uses various techniques to induce symptoms in a child—giving the child drugs, tampering with medications, contaminating a feed- ing tube, or even smothering the child, for example. The illness can take almost any form, but the most common symptoms are

bleeding, seizures, asthma, comas, diar- rhea, vomiting, "accidental" poisonings, infections, fevers, and sudden infant death syndrome (Leamon et al., 2007; Feldman,

2004). Between 6 and 30 percent of the vic-

tims of Munchausen syndrome by proxy die as a result of their symptoms, and 8 percent of those who survive are permanently disfigured or physically im- paired (Ayoub, 2006; Mitchell, 2001). Psychological, educational, and physical

• • 1■ • • •

development are also affected (Libow & Schreier, 1998; Libow, 1995).

The syndrome is very hard to diagnose and may be more common than clinicians once thought (Feldman, 2004; Rogers, 2004). The parent (usually the mother) seems to be so devoted and caring that others sympathize with and admire her. Yet the physical problems disappear when child and parent are separated. In many cases siblings of the sick child have also been victimized {Ayoub, 2006).

What kind of parent carefully inflicts pain and illness on her own child? The typical Munchausen mother is emotionally needy: She craves the attention and praise she receives for her devoted care of her sick child (Noeker, 2004). She may have little social support outside the medical

system. Often the mothers have a medical background of some kind—perhaps hav- ing worked formerly in a doctor's office. Typically they deny their actions, even in the face of clear evidence, and refuse to undergo therapy (Bluglass, 2001).

Law enforcement authorities approach Munchausen syndrome by proxy as a crime—a carefully planned form of child abuse (Slovenko, 2006; Mart, 2004). They almost always require that the child be separated from the mother (Ayoub, 2006). At the same time, a parent who resorts to such actions is seriously disturbed and greatly in need of clinical help. Thus clini- cal researchers and practitioners must now work to develop clearer insights and more effective treatments for such parents and their young victims.

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Somatoform and Dissociative Disorders 1 69

journeyed from tavern to tavern in Europe telling fantastical tales about his supposed military adventures (Ford, 2005; Feldman, 2004). In a related disorder, Munchausen syndrome by proxy, or factitious disorder by proxy, parents make up or produce physical illnesses in their children, leading in some cases to repeated painful diagnostic tests, medication, and surgery.

What Are Preoccupation Somatoform Disorders? Hypochondriasis and body dysmorphic disorder are preoccupation somatoform disor- ders. People with these problems misinterpret and overreact to bodily symptoms or features no matter what friends, relatives, and physicians may say. Although preoccupa- tion disorders also cause great distress, their impact on one's life differs from that of hysterical disorders.

Hypochondriasis People who suffer from hypochondriasis unrealistically interpret bodily symp toms as signs ofa serious illness (seeTable 6-2). Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or sweating. Although sonic patients recognize that their concerns are excessive, many do not.

Although hypochondriasis can begin at any age, it starts most often in early adult- hood, among men and women in equal numbers. Between 1 and 5 percent of all people experience the disorder (Bouman, 2008; APA, 2000). As with pain disorder associated with psychological factors, physicians report seeing many cases (Mitchell, 2004). As many as 7 percent of all patients seen by primary care physicians may display hypo- chondriasis (Asmundson & Taylor, 2008). For most patients, the symptoms rise and fall over the years.

Body Dysmorphic Disorder People who experience body dysmorphic disor- der, also known as dysmorphophobia, become deeply concerned about some imag- ined or minor defect in their appearance (see again Table 6-2). Most often they focus on wrinkles; spots on the skin; excessive facial hair; swelling of the face; or a misshapen nose, mouth, jaw, or eyebrow (McKay, Gosselin, & Gupta, 2008; Veale, 2004). Some worry about the appearance of their feet, hands, breasts, penis, or other body parts. Still others are concerned about bad odors coming from sweat, breath, genitals, or the rectum (Phillips & Castle, 2002). Here we see such a case:

A woman of 35 had for 16 years been worried that her sweat smelled terrible. The fear began just before her marriage when she was sharing a bed with a close friend who said that someone at work smelled badly, and the patient felt that the remark was directed at her. For fear that she smelled, for 5 years she had not gone out anywhere except when ac- companied by her husband or mother. She had not spoken to her neighbors for 3 years be- cause she thought she had overheard them speak about her to some friends. She avoided cinemas, dances, shops, cafes, and private homes. . . . Her husband was not allowed to invite any friends home; she constantly sought reassurance from him about her smell... . Her husband bought all her new clothes as she was afraid to try on clothes in front of shop assistants. She used vast quantities of deodorant and always bathed and changed her clothes before going out, up to 4 times daily.

(Marks, 1987, p. 371)

It is corrunon in our society to worry about appearance (see Figure 6-2 on the next page). Many teenagers and young adults worry about acne, for instance. The concerns of people with body dysmorphic disorder, however, are extreme. Sufferers may severely limit contact with other people, be unable to look others in the eye, or go to great lengths to conceal their "defects"—say, always wearing sunglasses to cover their supposedly misshapen eyes (Phillips, 2005). As many as half of people with this disorder seek plastic surgery or

oMunchausen syndromeoThe extreme and chronic form of factitious disorder.

°Munchausen syndrome by proxy°. A factitious disorder in which parents make up or produce illnesses in their children. Also known as factitious disor- der by proxy.

°preoccupation somatoform drsorders.Disorders in which people misinterpret and overreact to minor, even normal, bodily symptoms or features.

ehypochondriasisoA disorder in which people mistakenly fear that minor changes in their physical functioning indicate a serious disease.

°body dysmorphic disorderoA disorder marked by excessive worry that some aspect of one's physical appearance is defective. Also known as dysmorphophobia.

People who would change something about their appearance

if they could

People who daydream about being beautiful or handsome

People who think that the cosmetics industry is very important

or essential to our country

People who wear uncomfortable shoes because they look good

People who have brushed their teeth twice in the last 24 hours

People who have flossed their teeth in the last 24 hours

People who have stuffed their bras (women) or shorts (men)

170 :/JCHAPTER 6

dermatology treatment, and often they feel worse rather than better afterward (McKay et al., 2008). One study found that 30 percent of participants with body dysmorphic disorder were housebound and 17 percent had attempted suicide (Phillips et al., 1993).

Most cases of body dysmorphic disorder begin during adolescence. Often, however, people don't reveal their concerns for many years (McKay et al., 2008). Up to 5 percent of people in the United States—including many college students—suffer from the disorder (Ovsiew, 2006; Miller, 2005). Clinical reports suggest that it may be equally common among women and men (APA, 2000).

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What Causes Somatoform Disorders? Theorists typically explain the preoccupation somatoform disorders much as they explain anxiety disorders (Bouman, 2008; Noyes, 2008, 2003, 2001). Behaviorists, for example, believe that the fears found in hypochondriasis and body dysmorphic disorder

are acquired through classical conditioning or modeling (Marshall et al., 2007). Cognitive theorists suggest that people with the dis- orders are so sensitive to and threatened by bodily cues that they come to misinterpret them (Williams, 2004).

In contrast, the hysterical somatoform disorders—conversion, somatization, and pain disorders—are widely considered unique and in need of special explanations. The ancient Greeks believed that only women had hysterical disorders. The uterus of a sexually ungratified woman was supposed to wander throughout her body in search of fulfillment, producing a physical symptom wherever it lodged. Thus Hippocrates suggested marriage as the most effec- tive treatment for such disorders. Today's leading explanations for hysterical somatoform disorders come from the psychodynamic, behavioral, cognitive, and multicultural models. None has received much research support, however, and the disorders are still poorly understood (Kirmayer & Looper, 2007;Yutzy, 2007).

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Somataform and Dissociative Disorders :1/ 1 71

eauty is in the Eye of the Beholder

eople almost everywhere want to be attractive, and they tend to worry

about how they appear in the eyes of oth- ers. At the same time, these concerns take different forms in different cultures.

Whereas people in Western society worry in particular about their body size and facial features, women of the Padaung tribe in Myanmar focus on the length of their neck and wear heavy stacks of brass rings to try to extend it. Many of them seek desperately to achieve what their culture has taught them is the perfect neck size. Said one, "It is most beautiful when the neck is really long. . . . I will never take off my rings. . . I'll be buried in them" (Mydans, 1996).

Similarly, for centuries women of China, in response to the preferences of men in that country, worried greatly about the size and appearance of their feet and practiced foot binding to stop the growth of these extremities (Wang Ping, 2000). In this procedure, which began in the year 900

and was widely practiced until it was outlawed in 1911, young girls were instructed to wrap a long ban- dage tightly around their feet each day, forcing the four toes under the sole of the foot. The procedure, which was carried out for about two years, caused the feet to become narrower and smaller. Typically the practice led to serious medical problems and poor mobility, but it did produce the small feet that were considered attractive.

Western society also falls victim to such cultural influences. Recent decades have witnessed staggering increases in such procedures as rhinoplasty (reshaping of the nose), breast augmentation, and body piercing-all reminders that cul- tural values greatly influence each person's ideas and concerns about beauty, and in some cases may set the stage for body dysmorphic disorder.

The Psychodynamic View As you read in Chapter 1, Freud's theory of psycho- analysis 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 pro blems.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 0., who suffered from hysterical deafness, disorga- nized speech, and paralysis. Critics have since questioned whether Anna's ailments were entirely hysterical and whether Breuer's treatment helped her as much as he claimed (Ellenberger, 1972). But on the basis of this and similar cases, Freud (1894) came to be- lieve that hysterical disorders represented a conversion of underlying emotional conflicts into physical symptoms.

Observing that most of his patients with hysterical disorders were women, Freud centered his explanation of hysterical 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 experience an unconscious need to hide them from both herself and others. Freud concluded that some women hide their sexual feelings by unconsciously convert- ing them into physical symptoms.

172 :it/CHAPTER 6

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Most of today's psychodynamic theorists take issue with Freud's expla- nation of hysterical disorders, particularly his notion that the disorders can always be traced to an unresolved Electra conflict (Verhaeghe,Vanheule, & de Rick, 2007; Hess, 1995).They continue to believe, however, that sufferers of these disorders have unconscious conflicts carried forth from childhood, which arouse anxiety, and that the individuals convert this anxiety into "more tolerable" physical symptoms (Brown et al., 2005).

Psychodynamic theorists propose that two mechanisms are at work in hysterical somatoform disorders—primary gain and secondary gain (van Egmond, 2003). People achieve primary gain when their hysterical symptoms keep their internal conflicts out of awareness. During an argument, for ex- ample, 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 achieve secondary gain when their hysterical 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, from telling his

wife's parents of her death to attending her funeral and returning to work.

The Behavioral View Behavioral theorists propose that the physical symptoms of hysterical disorders bring rewards to sufferers (see Table 6-3). Perhaps the symptoms remove the individuals from an unpleasant relationship or bring attention from other people (Whitehead et al., 1994). In response to such rewards, the sufferers learn to dis- play the symptoms more and more prominently. Behaviorists also hold that people who are familiar with an illness will more readily adopt its physical symptoms (Garralda, 1996). In fact, studies find that many sufferers develop their hysterical symptoms after they or their close relatives or friends have had similar medical problems (Marshall et al., 2007). Clearly, the behavioral focus on rewards is similar to the psychodynamic idea of secondary gains.

Like the psychodynamic explanation, the behavioral view of hysterical 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 may bring.

The Cognitive View Some cognitive theorists propose that hysterical disorders are forms of communication, providing a means for people to express emotions that would otherwise be difficult to convey (Mitchell, 2004). Like their psychodynamic colleagues, these theorists hold that the emotions of patients with hysterical disorders are being con- verted into physical symptoms. They suggest, however, that the purpose of the conver- sion 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 patient (Koh et al., 2005).

According to this view, people who find it particularly hard to recognize or express their emotions are candidates for a hysterical disorder. 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 par- ticularly likely to develop physical symptoms as a form of communication (Dhossche et al., 2002). Like the other explanations, this cognitive view has not been widely tested or supported by research.

The Multicultural View Clinicians often use the term somatization when referring generally to the development of somatic symptoms in response to personal distress, the key feature of hysterical somatoform disorders. Somatization of any kind is considered inappropriate in Western countries (So, 2008; Escobar, 2004). Some theorists believe,

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Disorders That Have Physical Symptoms

Disorder

Voluntary Control of Symptoms?

Symptoms Linked to Psychosocial Factor?

An Apparent Goal?

Malingering Yes Maybe Yes

Factitious disorder Yes Yes No*

Somatoform disorder No Yes Maybe

Psychophysiological disorder No Yes No

Physical illness No Maybe No

*Except for medical attention.

however, that this position reflects a bias held by Western clinicians—a bias that sees so- matic symptoms as an inferior way of dealing with emotions (Moldaysky, 2004; FAbrega, 1990).

In fact, the transformation of personal distress into somatic complaints is the norm in many non-Western cultures (Draguns, 2006; Kleinman, 1987). In such cultures, somatization is viewed as a socially and medically correct—and less stigmatizing— reaction to life's stressors.

Studies have found very high rates of somatization in non-Western medical settings throughout the world, including those in China, Japan, and Arab countries (Matsumoto

Juang, 2008). Individuals in Latin countries seem to display the greatest number of somatic symptoms (Escobar, 2004, 1995; Escobar et al., 1998, 1992). Even within the United States, people from Hispanic cultures display more somatic symptoms in the face of stress than do other populations.

In Chapter 5 you saw that posttraumatic stress disorder may be more common among Hispanic Americans than among other ethnic groups in the United States (see page 143). Interestingly, however, research clarifies that this trend exists only among Hispanic Americans who were born in the United States or have lived in the United States for a number of years (Escobar, 2004, 1998). Indeed, recent Latin immigrants display a lower rate of posttraumatic stress disorder than do other individuals throughout the country. It may be that recent immigrants, not yet influenced by the Western bias against somatization, react to traumatic events with familiar somatic symptoms and that those symptoms help prevent the onset of a full-blown posttraumatic stress disorder.

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

I E., r A Possim e Kole for Biology Although hysterical somatoform disorders are, by definition, thought to result largely from psychological and sociocultural factors, the im- pact of biological processes should not be overlooked (Ovsiew, 2006).To understand this point, consider first what researchers have learned about placebos and the placebo effect.

For centuries physicians have observed that patients suffering from many kinds of illnesses, fro m seasickness to angina, often find relief from placebos, substances that have no known medicinal value (Price, Finniss, & Benedetti, 2008; Brody, 2000). Some studies have raised questions about the actual number of patients helped by placebos (Hrobjartsson & Gotzsche, 2006, 2001), but it is generally agreed that such "pretend" treatments do bring help to many people.

Why do placebos have a medicinal effect? Theorists used to believe that they operated in purely psychological ways—that the power of suggestion worked almost magically

oplacebooA sham treatment that a patient believes to be genuine.

Somatoform and Dissociative Disorders :1/ 173

174 ://CHAPTER 6

"If this doesn't help you don't worry, it's a placebo."

upon the body. More recently, however, researchers have found that a belief or expecta- tion can trigger certain chemicals throughout the body into action, and these chemicals then may produce a medicinal effect (Price et al., 2008). The body chemicals most often mentioned are hormones and lymphocytes, chemicals that you observed at work in Chap- ter 5, and endorphins, natural opioid substances that you will read about in Chapter 10. Howard Brody, a leading theorist on the subject, compares the placebo effect to visiting a pharmacy:

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Our bodies are capable of producing many substances that can heal a wide variety of ill- nesses, and make us feel generally healthier and more energized. When the body simply secretes these substances on its own, we have what is often termed "spontaneous healing." Some of the time, our bodies seem slow to react, and a message from outside can serve as a wake-up call to our inner pharmacy.The placebo response can thus be seen as the reaction of our inner pharmacies to that wake-up call.

(Brody, 2000, p. 61)

If placebos can "wake up" our inner pharmacies in this way, perhaps traumatic events and related concerns or needs are doing the same thing (although in a negative way) in cases of conversion disorder, somatization disorder, or pain disorder associated with psychological factors. That is, such events and reactions may, in fact, be triggering our inner pharmacies and setting in motion the bodily symptoms of hysterical somatoform disorders.

How Are Somatoform Disorders Treated? People with somatoform disorders usually seek psychotherapy only as a last resort. They fully believe that their problems are medical and at first reject all suggestions to the contrary (Asmundson & Taylor, 2008). When a physician tells them that their problems have no physical basis, they often go to another physician. Eventually, however, many patients with these disor-

Somata form and Dissociative Disorders :1/ 175

ders do consent to psychotherapy, psychotropic drug therapy, or both.

Individuals with preoccupation somatoform disorders- hypochondriasis and body dysmorphic disorder—typically receive the kinds of treatment that are applied to anxiety disor- ders, particularly obsessive-compulsive disorder. Studies reveal, for example, that patients with either of the preoccupation disorders often improve considerably when treated with the same antidepressant drugs that are helpful in cases of obsessive- compulsive disorder (Bouman, 2008; McKay et al., 2008).

Similarly, in one study, 17 patients with body dysmorphic disorder were treated with exposure and response prevention—the behavioral approach that often helps persons with obsessive- compulsive disorder. Over the course of four weeks, the clients were repeatedly reminded of their perceived physical defects and, at the same time, prevented from doing anything to help reduce their discomfort (for example, checking their appear- ance) (Neziroglu et al., 2004, 1996). By the end of treatment, these individuals were less concerned with their "defects" and spent less time checking their body parts and avoiding social interactions. Increasingly, this behavioral approach is being successfully combined with a cognitive approach that also helps clients with body dysmorphic disorder identify, test, and change their distorted thoughts about their appearance and social impact (Sarwer et al., 2004; Geremia & Neziroglu, 2001).

Cognitive-behavioral therapies of this kind are also being applied to cases of hypo- chondriasis . Here, therapists repeatedly point out bodily variations to clients while, at the same time, preventing them from seeking their usual medical attention. In addition, the therapists guide the clients to identify and change the illness-related beliefs that are helping to maintain their disorder. Once again, such approaches are receiving promising research support (Bouman, 2008; Greeven et al., 2007).

Treatments for hysterical somatoform disorders—conversion, somatization, and pain disorders—often focus on the cause of the disorder (the trauma or anxiety behind the physical symptoms) and apply the same kinds of techniques used in cases of posttrau- matic stress disorder, particularly insight, exposure, and drug therapies. Psychodynamic therapists, for example, try to help individuals with hysterical disorders become con- scious of and resolve their underlying fears, thus eliminating the need to convert anxiety into physical symptoms (Hawkins, 2004). Alternatively, behavioral therapists use expo- sure treatments:They expose clients to features of the horrific events that first triggered their physical symptoms, expecting that the individuals will become less anxious over the course of repeated exposures and, in turn, more able to face those upsetting events directly rather than through physical channels (Stuart et al., 2008).And biological thera- pists use antianxiety drugs or certain antidepressant drugs to help reduce the anxiety of clients with hysterical disorders (Eifert et al., 2008; Han et al., 2008).

Other therapists try to address the physical symptoms of the hysterical disorders rather than the causes, applying techniques such as suggestion, reinforcement, or confrontation (Yutzy, 2007).Those who employ suggestion offer emotional support to patients and tell them persuasively (or hypnotically) that their physical symptoms will soon disappear (Elkins & Perfect, 2007; Moene et al., 2002).Therapists who take a reinforcement approach arrange the removal of rewards for a client's "sick" behaviors and an increase of rewards for healthy behaviors (North, 2005). And therapists who take a confrontational approach try to force patients out of the sick role by straightforwardly telling them that their symptoms are without medical basis (Sjolie, 2002).

Researc hers have not fully evaluated the effects of these particular approaches on hysterical disorders (Ciano-Federoff & Sperry, 2005). Case studies suggest, however, that conversion disorder and pain disorder respond better than somatization disorder to therapy and that approaches using a confrontational strategy are less helpful than sug- gestion and reinforcement interventions (Miller, 2004).

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1 76 :I/CHAPTER 6

ememoryoThe faculty for recalling past events and past learning.

*dissociative disordersoDisorders marked by major changes in memory that do not have clear physical causes.

Somatoform Disorders

Patients with somatoform disorders have physical complaints whose causes are largely psychosocial. Nevertheless, the individuals genuinely believe that their ill- nesses are medical in origin.

Hysterical somatoform disorders involve an actual loss or change of physical functioning. They include conversion disorder, somatization disorder (or Briquet's syndrome), and pain disorder associated with psychological factors. Freud devel- oped the initial psychodynamic view of hysterical somatoform disorders, proposing that the disorders represent a conversion of underlying emotional conflicts into physi- cal symptoms. According to behaviorists, the physical symptoms of these disorders bring rewards to the sufferer, Some cognitive theorists propose that the disorders are forms of communication. Biological factors may also help explain these disorders, as we ore reminded by recent studies of placebos. Treatments for hysterical disorders emphasize either insight, suggestion, reinforcement, or confrontation.

People with preoccupation somatoform disorders are preoccupied with the notion that something is wrong with them physically. In this category are hypocho- driasis and body dysmorphic disorder. Theorists explain preoccupation somatoform disorders much as they do anxiety disorders. Treatment for the disorders includes medications, exposure and response prevention, and other treatments originally developed for anxiety disorders, particularly obsessive-compulsive disorder.

Dissociative Disorders Most of us experience a sense of wholeness and continuity as we interact with the world. We perceive ourselves as being more than a collection of isolated sensory experiences, feelings, and behaviors. In other words, we have an identity, a sense of who we are and where we fit in our environment. Others recognize us and expect certain things of us. But more important, we recognize ourselves and have our own expectations, values, and goals.

Memory is a key to this sense of identity, the link between our past, present, and fu- ture. Our recall of past experiences, although not always precisely accurate, helps us react to present events and guides us in making decisions about the future.We recognize our friends and relatives, teachers and employers, and respond to them in appropriate ways. Without a memory, we would always be starting over; with it, life moves forward.

People sometimes experience a major disruption of their memory. They may, for example, lose their ability to remember new information they just learned or old in- formation they once knew well. When such changes in memory lack a clear physical cause, they are called dissociative disorders. In such disorders, one part of the person's memory typically seems to be dissociated, or separated, from the rest.

There are several kinds of dissociative disorders.The primary symptom of dissociative amnesia is an inability to recall important personal events and information. A person with dissociative fiegue not only forgets the past but also travels to a new location and may assume a new identity. Individuals with dissociative identity disorder; also known as multiple personality disorder, have two or more separate identities that may not always be aware of each other's thoughts, feelings, and behavior.

Several memorable books and movies have portrayed dissociative disorders.Two of the best known are The Three Faces of Eve and Sybil, each about a woman with mul- tiple personalities. The topic is so fascinating that most television drama series seem to include at least one case of dissociation every season, creating the impression that the disorders are very common (Pope et al., 2007). Many clinicians, however, believe that they are rare.

Somatoforrn and Dissociative Disorders :1/ 1 77

DSM-IV-TR also lists depersonalization disorder as a disso- ciative disorder. People with this problem feel as though they have become detached from their own mental processes or body and are observing themselves from the outside. Because memory problems are not a central feature of this disorder, it will not be discussed here.

As you read through the remainder of this chapter, keep in mind that dissociative symptoms are often found in cases of acute or posttraumatic stress disorder. Recall from Chap- ter 5 that sufferers of those disorders may feel dazed or have trouble remembering things. When such symptoms occur as part of a stress disorder, they do not necessarily indicate a dissociative disorder, in which the dissociative symptoms dominate. On the other hand, research suggests that a num- ber of people with one of these disorders also develop the other as well (Bremner, 2002).

Dissociative Amnesia At the beginning of this chapter you met the unfortunate man named Brian. As you will recall, Brian developed a conversion disorder after a traumatic boating accident in which his wife was killed. To help examine dissociative amnesia, let us now revisit that case, changing the reactions and symptoms that Brian develops in the aftermath of the traumatic event.

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. After 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.

After 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 ... discussions with authorities . . . breaking the news to Helen's parents . conversations with friends . . . self-blame . . . grief . . . and more. On Wednesday, four days after that fateful afternoon, Brian collected himself and at- tended Helen's funeral and burial. It was the longest and most difficult day of his life. Most of the time, he felt as though he were in a trance.

Soon after awakening on Thursday morning, Brian realized that something was terribly wrong with him. Try though he might, he couldn't remember the events of the past few days. He remembered the occident, Helen's death, and the call from the Coast Guard after they had found her body. But just about everything else was gone, right up through the funeral. At first he had even thought that it was now Sunday, and that his discussions with family and friends and the funeral were all ahead of him. But the newspaper, the funeral guestbook, and a phone conversation with his brother soon convinced him that he had lost the post four days of his life.

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Repressed Childhood Memories or False Memory Syndrome?

hroughout the 1990s, reports of re- _ pressed childhood memory of abuse attracted much public attention. Adults with this type of dissociative amnesia seemed to recover buried memories of sexual and physical abuse from their childhood. A woman might claim, for example, that her father hod sexually molested her repeat. edly between the ages of 5 and 7. Or a young man might remember that a family friend had made sexual advances on sev- eral occasions when he was very young. Often the repressed memories surfaced during therapy for another problem.

Although the number of such claims has declined in recent years, experts remain split on this issue (Loftus & Cahill, 2007; McNally et al., 2005). Some believe that recovered memories are just what they ap- pear to be—horrible memories of abuse that have been buried for years in the person's mind. Other experts believe that the memories are actually illusions—false images created by a mind that is confused. Opponents of the repressed memory

concept hold that the details of childhood sexual abuse are often remembered all too well, not completely wiped from memory (Loftus & Cahill, 2007; McNally et al., 2004). They also point out that memory in general is often flawed (Lindsay et al., 2004). Moreover, false memories of vari- ous kinds can be created in the laboratory by tapping into research participants' imaginations (Brainerd, Reyna, & Ceci, 2008; Loftus & Cahill, 2007).

If the alleged recovery of childhood memories is not what it appears to be, what is it? According to opponents of the concept, it may be a powerful case of sug- gestibility (Loftus & Cahill, 2007; Loftus, 2003, 2001, 1997). These theorists hold that the attention paid to the phenomenon by both clinicians and the public has led some therapists to make the diagnosis without sufficient evidence (Frankel, 1993). The therapists may actively search for signs of early abuse in clients and even encour- age clients to produce repressed memories (Gardner, 2004). Certain therapists in fact

use special memory recovery techniques, including hypnosis, regression therapy, journal writing, dream interpretation, and interpretation of bodily symptoms (Madill & Holch, 2004; Lindsay, 1996, 1994). Perhaps some clients respond to the tech- niques by unknowingly forming false mem- ories of abuse (Hyman & Loftus, 2002). The apparent memories may then become increasingly familiar to them as a result of repeated therapy discussions of the alleged incidents.

Of course, repressed memories of child- hood sexual abuse do not emerge only in clinical settings (Loftus & Cahill, 2007). Many individuals come forward on their own. Opponents of the repressed memory concept explain these cases by pointing to various books, articles, websites, and television shows that seem to validate repressed memories of childhood abuse (Loftus, 1993). Still other opponents of the repressed memory concept believe that, for biological or other reasons, some individu- als are more prone than others to experi- ence false memories—either of childhood abuse or of other kinds of events (McNally et al., 2005).

It is important to recognize that the experts who question the recovery of repressed childhood memories do not in any way deny the problem of child sexual abuse. In fact, proponents and opponents alike are greatly concerned that the public may take this debate to mean that clini- cians have doubts about the scope of the problem of child sexual abuse. Whatever may be the final outcome of the repressed memory debate, the problem of childhood sexual abuse is all too real and all too common.

178 ://CHAPTER 6

*dissociative amnesia®A disorder marked by an inability to recall important personal events and information.

In this revised scenario, Brian is reacting to his traumatic experience with symptoms of dissociative amnesia. People with this disorder are unable to recall important information, usually of an upsetting nature, about their lives (APA, 2000). The loss of memory is much more extensive than normal forgetting and is not caused by physical factors (see Table 6-4). Often an episode of amnesia is directly triggered by a specific upsetting event (McLeod et al., 2004).

Dissociative amnesia may be localized, selective, generalized, or continuous. Any of these kinds of amnesia can be triggered by a traumatic experience such as Brian's, but each represents a particular pattern of forgetting. Brian was suffering from localized amnesia,

the most common type of dissociative amnesia, in which a person loses all memory of events that took place within a limited period of time, almost always beginning with some very disturbing occurrence. Recall that Brian awakened on the day after the funeral and could not recall any of the events of the past difficult days, beginning after the boating tragedy. He remembered everything that happened up to and including the accident. He could also recall everything from the morning after the funeral onward, but the days in between remained a total blank. The forgotten period is called the amnestic episode. During an amnestic episode, people may appear confused; in some cases they wander about aimlessly. They are already experiencing memory difficulties but seem unaware of them. In the revised case, for example, Brian felt as though he were in a trance on the day of Helen's funeral.

People with selective amnesia, the second most common form of dissociative amnesia, remember some, but not all, events that occurred during a period of time. If Brian had selective amnesia, he might remember certain conversations with friends but perhaps not the funeral itself.

In some cases the loss of memory extends back to times long before the upsetting pe- riod. Brian might awaken after the funeral and find that, in addition to forgetting events of the past few days, he could not remember events that occurred earlier in his life. In this case, he would be experiencing generalized amnesia. In extreme cases, Brian might not even remember who he was and might fail to recognize relatives and friends.

In the forms of dissociative amnesia discussed so far, the period affected by the amne- sia has an end. In continuous amnesia, however, forgetting continues into the present. Brian might forget new and ongoing experiences as well as what happened before and during the tragedy. Continuous forgetting of this kind is actually quite rare in cases of dissociative amnesia but not, as you will see in Chapter 15, in cases of organic amnesia.

All of these forms of dissociative amnesia are similar in that the amnesia interferes mostly with a person's memory of personal material. Memory for abstract or ency- clopedic information usually remains. People with dissociative amnesia are as likely as anyone else to know the name of the president of the United States and how to write, read, or drive a car.

Clinicians do not know how common dissociative amnesia is (Pope et al., 2007), but they do know that many cases seem to begin during serious threats to health and safety, as in wartime and natural disasters (Cardena & Gleaves, 2007). Combat veterans often report memory gaps of hours or days, and some forget personal information, such as

Somatoform and Dissociative Disorders :1/ 1 79

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their names and addresses (Bremner, 2002). It appears that childhood abuse, particularly child sexual abuse, can also sometimes trigger dissociative amnesia; indeed, the 1990s witnessed many reports in which adults claimed to recall long-forgotten experiences of childhood abuse. In addition, dissociative amnesia may occur tinder more ordinary circumstances, such as the sudden loss of a loved one through rejection or death or guilt over certain actions (for example, an extramarital affair) (Koh et al., 2000).

The personal impact of dissociative amnesia depends on how much is forgotten. Obviously, an amnestic episode of two years is more of a problem than one of two hours. Similarly, an amnestic episode during which a person's life changes in major ways causes more difficulties than one that is quiet.

Dissociative Fugue People with a dissociative fugue not only forget their per- sonal identities and details of their past lives but also flee to an entirely different location (see again Table 6-4). Some individu- als travel a short distance and make few social contacts in the new setting (APA, 2000).Their fugue may be brief—a matter of hours or days—and end suddenly. In other cases, however, the person may travel far from home, take a new name, and establish a new identity, new relationships, and even a new line of work. Such people may also display new personality characteristics; often they are more outgoing (APA, 2000). This pattern is seen in the century-old case of the Reverend Ansel Bourne:

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°dissociative fugueoA disorder in which a person travels to a new location and may assume a new identity, simulta- neously forgetting his or her past.

On January 17, 1887, [the Reverend Ansel Bourne, of Greene, RI.] drew 551 dollars from a bank in Providence with which to pay for a certain lot of land in Greene, paid certain bills, and got into a Pawtucket horsecar. This is the last incident which he remembers. He did not return home that day, and nothing was heard of him for two months. He was published in the papers as missing, and foul play being suspected, the police sought in vain his whereabouts. On the morning of March 14th, however, at Norristown, Pennsylvania, a man calling himself A. 1. Brown who had rented a small shop six weeks previously, stocked it with stationery, confectionery, fruit and small articles, and carried on his quiet trade with- out seeming to any one unnatural or eccentric, woke up in a fright and called in the people of the house to tell him where he was. He said that his name was Ansel Bourne, that he was entirely ignorant of Norristown, that he knew nothing of shop-keeping, and that the last thing he remembered—it seemed only yesterday—was drawing the money from the bank, etc. in Providence.. . . He was very weak, having lost apparently over twenty pounds of flesh during his escapade, and had such a horror of the idea of the candy-store that he refused to set foot in it again.

(James, 1890, pp. 391-393)

Approximately 0.2 percent of the population experience dissociative fugue. Like dis- sociative amnesia, a fugue usually follows a severely stressful event (Cardena & Gleaves, 2007; APA, 2000). Some adolescent runaways may be in a state of fugue (Loewenstein, 1991). Like cases of dissociative amnesia, fugues usually affect personal memories rather than encyclopedic or abstract knowledge (Maldonado & Spiegel, 2007).

Fugues tend to end abruptly. In some cases, as with Reverend Bourne, the person "awakens" in a strange place, surrounded by unfamiliar faces, and wonders how he or she got there. In other cases, the lack of personal history may arouse suspicion. Perhaps a traffic accident or legal problem leads police to discover the false identity; at other times friends search for and find the missing person.When people are found before their state of fugue has ended, therapists may find it necessary to ask them many questions

Sornatoform and Dissociative Disorders :1/ 181

Homeward Hound: A Case of Dog Fugue?

BY SHERRY MORSE, ANIMAL NEWS, DECEMBER 13, 2003

he Flores family of Wichita, Kansas received an early

Christmas present this year when their beloved dog Bear,

who had disappeared in November of 1997, made it back

home in time for Thanksgiving in 2003.

Jeanie Flores looked out the window of her house two days

before Thanksgiving to see a dog that looked exactly like Bear

standing outside. She recalls thinking, "Oh my God. I think

that's my dogl" She called the dog; and he responded.

Jeanie burst into tears, then called her husband Frank and

told him she thought Bear was really home. Frank Flores rushed

home and, after seeing the dog, agreed with his wife that the

brindle lab-chow mix was indeed their Bear. One of the family's

neighbors told them she had spotted Bear a little earlier, walking

around and carefully scrutinizing the houses.

A veterinarian who examined Bear said that although his

paws were red and sore in spots, probably from pounding the

pavement, he only weighed one pound less than when he disap-

peared. It appeared that someone had been taking care of him.

Bear had disappeared in 1997 about one month after the

Flores family had moved to a new neighborhood. Jeanie let him

out for exercise one night, and he never came back. "I waited

up all night for him, and he never came home," she said.

At the time, Bear's ID tag had not yet been updated with his

new address. The desperate family put up signs, canvassed their

old neighborhood, ran ads in the paper, and visited shelters,

but, tragically, the dog that Mr. Flores had brought home as a

puppy in 1990 seemed to have disappeared without a trace.

Since his extraordinary return home six years later, Bear has

been catching up on his sleep and getting re-acquainted with

his family, which includes a son who was not yet born when the dog disappeared.

The Flores family said they just wish that Bear could tell them

where he's been all this time. "Where was he? We don't know

how rough a life he's had," Frank Flores said.

about the details of their lives, repeatedly remind them who they are, and even begin psychotherapy before they recover their memories. As these people recover their past, some forget the events of the fugue period (APA, 2000).

The majority of people who experience dissociative fugue regain most or all of their memories and never have a recurrence. Since fugues are usually brief and totally reversible, individuals tend to experience few aftereffects. People who have been away for months or years, however, often do have trouble adjusting to the changes that have occurred during their flights. In addition, some people commit illegal or violent acts in their fugue state and later must face the consequences.

Dissociative Identity Disorder (Multiple Personality Disorder) Dissociative identity disorder is both dramatic and disabling, as we see in the case of Eric:

Dazed and bruised from a beating, Eric, 29, was discovered wandering around a Day- tona Beach shopping mall on Feb. 9. . . . Transferred six weeks later to Daytona Beach's Human Resources Center, Eric began talking to doctors in two voices: the infantile rhythms of "young Eric," a dim and frightened child, and the measured tones of "older Eric," who told a tale of terror and child abuse. According to "older Eric," after his immigrant German parents died, a harsh stepfather and his mistress took Eric from his native South

182 ://CHAPTER 6

°dissociative identity disorder-0A dis- order in which a person develops two or more distinct personalities. Also known as multiple personality disorder.

osubpersonalitiesoThe two or more distinct personalities found in individuals suffering with dissociative identity disorder. Also known as alternate personalities.

Carolina to a drug dealers' hideout in a Florida swamp. Eric said he was raped by several gang members and watched his stepfather murder two men.

One day in late March an alarmed counselor watched Eric's face twist into a violent snarl. Eric let loose an unearthly growl and spat out a stream of obscenities. "It sounded like something out of The Exorcist," says Malcolm Graham, the psychologist who directs the case at the center. "it was the most intense thing rye ever seen in a patient." That disclosure of a new personality, who insolently demanded to be called Mark, was the first indication that Graham had been dealing with a rare and serious emotional disorder: true multiple personality... .

Eric's other manifestations emerged over the next weeks: quiet, middle-aged Dwight; the hysterically blind and mute Jeffrey; Michael, an arrogant jock; the coquettish Tian, whom Eric considered a whore; and argumentative Phillip, the lawyer. "Phillip was always asking about Eric's rights," says Graham. "He was kind of obnoxious. Actually, Phillip was a pain."

To Graham's astonishment, Eric gradually unfurled 27 different personalities, including three females. . . They ranged in age from a fetus to a sordid old man who kept trying to persuade Eric to fight as a mercenary in Haiti. In one therapy session, reports Graham, Eric shifted personality nine times in an hour. "I felt i was losing control of the sessions," says the psychologist, who has eleven years of clinical experience. "Some personalities would not talk to me, and some of them were very insightful into my behavior as well as Eric's."

(Time, October 25, 1982, p. 70)

A person with dissociative identity disorder, or multiple personality disorder, develops two or more distinct personalities, often called subpersonalities or alternate personalities, each with a unique set of memories, behaviors, thoughts, and emotions (see Table 6-5). At any given time, one of the subpersonalities takes center stage and dominates the person's functioning. Usually one subpersonality, called the primary, or host, personality, appears more often than the others.

The transition from one subpersonality to another, called switching, is usually sud- den and may be dramatic (APA, 2000). Eric, for example, twisted his face, growled, and yelled obscenities while changing personalities. Switching is usually triggered by a stressful event, although clinicians can also bring about the change with hypnotic sug- gestion (APA, 2000).

Cases of dissociative identity disorder were first reported almost three centuries ago (Bieber, 2002). Many clinicians consider the disorder to be rare, but some reports sug- gest that it may be more common than was once thought (Sar et al., 2007; APA, 2000). Most cases are first diagnosed in late adolescence or early adulthood, but, more often than not, the symptoms actually began in early childhood after episodes of abuse (often sexual abuse), perhaps even before the age of 5 (Maldonado Sc Spiegel, 2007; Roe-Sepowitz et al., 2007).Women receive this diagnosis at least three times as often as men (APA, 2000).

How Do Subpersonalities nieraet? How subpersonalities relate to or recall one another varies from case to case. Generally, however, there are three kinds of relationships. In mutually amnesic relationships, the subpersonalities have no awareness of one another (Ellenberger, 1970). Conversely, in mutually cognizant patterns, each subpersonality is well aware of the rest. They may hear one another's voices and even talk among themselves. Some are on good terms, while others do not get along at all.

In one-way amnesic relationships, the most common relationship pattern, some subper- sonalities are aware of others, but the awareness is not mutual (Huntjens et al., 2005). Those who are aware, called co-conscious subpersonalities, are "quiet observers" who watch the actions and thoughts of the other subpersonalities but do not interact with them. Sometimes while another subpersonality is present, the co-conscious personality makes itself known through indirect means, such as auditory hallucinations (perhaps a voice giving commands) or "automatic writing" (the current personality may find itself writ- ing down words over which it has no control).

Profit Distributions

Somatoform and Dissociative. Disorders 1 83

Investigators used to believe that most cases of dissociative identity disorder involved two or three subpersonalities. Studies now suggest, however, that the average number of subpersonalities per patient is much higher-15 for women and 8 for men (APA, 2000). In fact, there have been cases in which 100 or more subpersonalities were observed. Often the subpersonalities emerge in groups of two or three at a time.

In the case of "Eve White," made famous in the book and movie The Three Faces of Eve, a woman had three subpersonalities—Eve White, Eve Black, and Jane (Thigpen & Cleckley, 1957). Eve White, the primary personality, was quiet and serious; Eve Black was carefree and mischievous; and Jane was mature and intelligent. According to the book, these three subpersonalities eventually merged into Evelyn, a stable personality who was really an integration of the other three.

The book was mistaken, however; this was not to be the end of Eve's dissociation. In an autobiography 20 years later, she revealed that altogether 22 subpersonalities had come forth during her life, including 9 subpersonalities after Evelyn. Usually they ap- peared in groups of three, and so the authors of The Three Faces of Eve apparently never knew about her previous or subsequent subpersonalities. She has now overcome her disorder, achieving a single, stable identity, and has been known as Chris Sizemore for over 30 years (Sizemore, 1991).

How Do Subpersonalities Differ? As in Chris Sizemore's case, subpersonalities often exhibit dramatically different characteristics.They may also have their own names and different identifying features, abilities and preferences, and even physiological responses.

IDENTIFYING FEATURES The subpersonalities may differ in features as basic as age, gender, race, and family history, as in the famous case of Sybil Dorsett. Sybil's dissociative identity disorder has been described in fictional form (in the novel Sybil) but is based on the real case of a patient named Shirley Ardell Mason, from the practice of psychiatrist Cornelia Wilbur (Schreiber, 1973). Sybil displayed 17 subpersonalities, all with different identify- ing features. They included adults, a teenager, and a baby named Ruthie; two were male, named Mike and Sid. Sybil's subpersonalities each had particular images of themselves and of each other.The subpersonality named Vicky, for example, saw herself as an attrac- tive blonde, while another, Peggy Lou, was described as a pixie with a pug nose. Mary was plump with dark hair, and Vanessa was a tall redhead with a willowy figure.

ABILITIES AND PREFERENCES Although memories of abstract or encyclopedic information are not usually affected in dissociative amnesia or fugue, they are often disturbed in dis- sociative identity disorder. It is not uncommon for the different subpersonalities to have different abilities: One may be able to drive, speak a foreign language, or play a musical instrument, while the others cannot (Coons & Bowman, 2001; Coons et al., 1988). Their handwriting can also differ. In addition, the subpersonalities usually have different tastes in food, friends, music, and literature. Chris Sizemore ("Eve") later pointed out, "If I had learned to sew as one personality and then tried to sew as another, I couldn't do it. Driving a car was the same. Some of my personalities couldn't drive" (Sizemore & Pitillo, 1977, p. 4).

PHYSIOLOGICAL RESPONSES Researchers have discovered that subpersonalities may have physiological differences, such as differences in autonomic nervous system activity, blood pressure levels, and allergies (Putnam, Zahn, & Post, 1990). One study looked at the brain activities of different subpersonalities by measuring their evoked potentials—that is, brain-response patterns recorded on an electroencephalograph (Putnam, 1984). The brain pattern a person produces in response to a specific stimulus (such as a flashing light) is usually unique and consistent. However, when an evoked potential test was administered to four subpersonalities of each of 10 people with dissociative identity disorder, the results were dramatic. The brain-activity pattern of each subpersonality was unique, showing the kinds of variations usually found in totally different people.

How Common Is Dissociative Identity Disorder? As you have seen, dissocia- tive identity disorder has traditionally been thought ofas rare. Some researchers even argue

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that many or all cases are iatrogenic— that is, unintentionally produced by practitioners (Loewenstein, 2007; Piper & Merskey, 2005, 2004). They believe that therapists create this disorder by subtly suggesting the exis- tence of other personalities during therapy or by explicitly asking a pa- tient to produce different personalities while under hypnosis. In addition, they believe, a therapist who is looking for multiple personalities may reinforce these patterns by displaying greater interest when a patient dis- plays symptoms of dissociation.

These arguments seem to be supported by the fact that many cases of dissociative identity disorder first come to attention while the person is already in treatment for a less serious problem. But such is not true of all cases; many people seek treatment because they have noticed time lapses throughout their lives or because relatives and friends have observed their subpersonalities (Putnam, 2000, 1988, 1985).

The number of people diagnosed with dissociative identity disorder has been increasing (Sar et al., 2007; Casey, 2001).Although the disorder

is still uncommon, thousands of cases have now been diagnosed in the United States and Canada alone. Two factors may account for this increase. First, a growing number of today's clinicians believe that the disorder does exist and are willing to diagnose it (Merenda, 2008; Lalonde et al., 2002, 2001). Second, diagnostic procedures tend to be more accurate today than in past years. For much of the twentieth century, schizophrenia was one of the clinical field's most commonly applied diagnoses. It was applied, often incorrectly, to a wide range of unusual behavioral patterns, perhaps including dissociative identity disorder (Turkington & Harris, 2009, 2001). Under the stricter criteria of recent editions of the DSM, clinicians are now more accurate in diagnosing schizophrenia, allowing more cases of dissociative identity disorder to be recognized (Welborn et al., 2003). In addition, several diagnostic tests have been developed to help detect dissocia- tive identity disorder (Cardena, 2008). Despite such changes, however, many clinicians continue to question the legitimacy of this category (Lalonde et al., 2002, 2001).

How Do Theorists Explain Dissociative Disorders? A variety of theories have been proposed to explain dissociative disorders. Older explanations, such as those offered by psychodynamic and behavioral theorists, have not received much investigation (Merenda, 2008). However, newer viewpoints, which combine cognitive, behavioral, and biological principles and highlight such factors as state- dependent learning and self- hypnosis, have captured the interest of clinical scientists.

The Psychodynamic View Psychodynamic theorists believe that dissociative disorders are caused by repression, the most basic ego defense mechanism: People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness. Everyone uses repression to a degree, but people with dissociative disorders are thought to repress their memories excessively (Fayek, 2002).

In the psychodynamic view, dissociative amnesia and fugue are single episodes of mas- sive repression. In each of these disorders, a person unconsciously blocks the memory of an extremely upsetting event to avoid the pain of facing it (Turkington & Harris, 2009, 2001). Repressing may be their only protection from overwhelming anxiety.

In contrast, dissociative identity disorder is thought to result from a lifetime of ex- cessive repression (Brenner, 2009, 1999; Wang & Jiang, 2007). Psychodynamic theorists believe that continuous use of repression is motivated by traumatic childhood events, particularly abusive parenting. Children who experience such traumas may come to fear the dangerous world they live in and take flight from it by pretending to be another person who is looking on safely from afar. Abused children may also come to fear the impulses that they believe are the reasons for their excessive punishments. Whenever they experience "bad" thoughts or impulses, they unconsciously try to disown and deny them by assigning them to other personalities.

Peculiarities of Memory

sually memory problems must interfere greatly with a person's functioning

before they are considered a sign of a disorder. Peculiarities of memory, on the other hand, fill our daily lives. Memory investigators have identified a number of these peculiarities—some familiar, some useful, some problematic, but none abnormal {Turkington & Harris, 2009, 2001; Mathews & Wang, 2007; Brown, 2004, 2003).

Absentmindedness Often we fail to register information because our thoughts are focusing on other things. If we haven't absorbed the information in the first place, it is no surprise that later we can't recall it.

Déjà vu Almost all of us have at some time had the strange sensation of recognizing a scene that we hap- pen upon for the first time. We feel sure we have been there before.

Jamais vu Sometimes we have the opposite experience: A situation or scene that is part of our daily life seems suddenly unfamiliar. "I knew it was my car, but I felt as if I'd never seen it before."

The tip-of-the-tongue phenom- enon To have something on the tip of the tongue is an acute "feeling of knowing": We are unable to recall

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kinds of information: They easily can bring to their mind the appearance of places, objects, faces, or the pages of a book. They almost never forget a face, yet they may well forget the name attached to it. Other people have stronger verbal memories: They remember sounds or words particularly well, and the memories that come to their minds are often puns or rhymes.

some piece of informa- tion, but we know that we know it.

Eidetic images Some people experience visual af- terimages so vividly that they can describe a picture in detail after looking at it just once. The images may be memories of pictures, events, fantasies, or dreams.

Memory while under anesthesia As many as 2 of every 1,000 anesthetized pa- tients process enough of what is said in their presence during surgery to affect their recovery. In many such cases, the ability to understand language has continued under anesthesia, even though the patient cannot explicitly recall it.

Memory for music Even as a small child, Mozart could memorize and reproduce a piece of music after having heard it only once. While no one yet has matched the genius of Mozart, many musicians can mentally hear whole pieces of music, so that they can rehearse anywhere, far from their instruments.

Visual memory Most people recall visual information better than other

"Did you ever start to do something and then forget what the heck it was?"

Somotoform and Dissociative Disorders 185

Most of the support for the psychodynamic position is drawn from case histories, which report such brutal childhood experiences as beatings, cuttings, burnings with cigarettes, imprisonment in closets, rape, and extensive verbal abuse.Yet some individu- als with dissociative identity disorder do not seem to have experiences of abuse in their background (Bliss, 1980). Moreover, child abuse appears to be far more common than dissociative identity disorder. Why might only a small fraction of abused children de- velop this disorder?

The Behavioral View Behaviorists believe that dissociation is a response learned through operant conditioning (Casey, 2001). People who experience a horrifying event may later find temporary relief when their minds drift to other subjects. For some, this momentary forgetting, leading to a drop in anxiety, increases the likelihood of future forgetting. In short, they are reinforced for the act of forgetting and learn—without being aware that they are learning—that such acts help them escape anxiety. Thus, like psychodynamic theorists, behaviorists see dissociation as escape behavior. But behavior- ists believe that a reinforcement process rather than a hardworking unconscious is keep- ing the individuals unaware that they are using dissociation as a means of escape. Like

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0state-dependent learningoLearning that becomes associated with the condi- tions under which it occurred, so that it is best remembered under the some conditions.

oseif-hypnosiseThe process of hypnotiz- ing oneself, sometimes for the purpose of forgetting unpleasant events.

hypnotic therapy®A treatment in which the patient undergoes hypnosis and is then guided to recall forgotten events or perform other therapeutic activ- ities. Also known as hypnotherapy.

psychodynarnic theorists, behaviorists have relied largely on case histories to support their view of dissociative disorders. Moreover, the behavioral explanation fails to explain precisely how temporary and normal escapes from painful memories grow into a com- plex disorder or why more people do not develop dissociative disorders.

State-Dependent Learning If people learn something when they are in a particular situation or state of mind, they are likely to remember it best when they are again in that same condition. If they are given a learning task while under the influence of alcohol, for example, their later recall of the information may be strongest under the influence of alcohol (Overton, 1966). Similarly, if they smoke cigarettes while learning, they may later have better recall when they are again smoking.

This link between state and recall is called state -dependent learning. It was initially observed in experimental animals who learned things while under the influence of certain drugs (Rezayof et al., 2008; Overton, 1966, 1964). Research with human partici- pants later showed that state-dependent learning can be associated with mood states as well: Material learned during a happy mood is recalled best when the participant is again happy, and sad-state learning is recalled best during sad states (de l'Etoile, 2002; Bower, 1981) (see Figure 6-3).

What causes state-dependent learning? One possibility is that arousal levels are an important part of learning and memory.That is, a particular level of arousal will have a set of remembered events, thoughts, and skills attached to it. When a situation produces that particular level of arousal, the person is more likely to recall the memories linked to it.

Although people may remember certain events better in some arousal states than in others, most can recall events under a variety of states. However, perhaps people who are prone to develop dissociative disorders have state-to-memory links that are unusually rigid and narrow. Maybe each of their thoughts, memories, and skills is tied exclusively to a particular state of arousal, so that they recall a given event only when they experience an arousal state almost identical to the state in which the memory was first acquired.When such people are calm, for example, they may forget what occurred during stressful times, thus laying the groundwork for dissociative amnesia or fugue. Similarly, in dissociative identity disorder, different arousal levels may produce entirely different groups of memories, thoughts, and abilities—that is, different subpersonalities (Dorahy & Huntjens, 2007; Putnam, 1992). This could explain why personality transi- tions in dissociative identity disorder tend to be sudden and stress-related.

Self-Hypnosis As you first saw in Chapter 1, people who are hypnotized enter a sleep- like state in which they become very suggestible.While in this state, they can behave, per- ceive, and think in ways that would ordinarily seem impossible. They may, for example, become temporarily blind, deaf, or insensitive to pain. Hypnosis can also help people remember events that occurred and were forgotten years ago, a capability used by many psychotherapists. Conversely, it can make people forget facts, events, and even their per- sonal identities—an effect called hypnotic amnesia.

The parallels between hypnotic amnesia and dissociative disorders are striking. Both are conditions in which people forget certain material for a period of time yet later remember it. And in both, the people forget without any insight into why they are forgetting or any awareness that something is being forgotten. These parallels have led some theorists to conclude that dissociative disorders may be a form of self-hypnosis in which people hypnotize themselves to forget unpleasant events (Maldonado & Spiegel, 2007, 2003). Dissociative amnesia may occur, for example, in people who, consciously or unconsciously, hypnotize themselves into forgetting horrifying experiences that have recently occurred in their lives. If the self-induced amnesia covers all memories of a person's past and identity, that person may undergo a dissociative fugue.

Participants who learned words in a sad mood

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Somatoform and Dissociative Disorders :11 1 87

Self-hypnosis might also be used to explain dissociative identity disorder. On the basis of several investigations, some theorists believe that this disorder often begins between the ages of 4 and 6, a time when children are generally very suggestible and excellent hypnotic subjects (Kluft, 2001, 1987; Bliss, 1985, 1980).These theorists argue that some children who experience abuse or other horrifying events manage to escape their threatening world by self-hypnosis, mentally separating themselves from their bod- ies and fulfilling their wish to become some other person or persons. One patient with multiple personalities observed, "I was in a trance often [during my childhood]. There was a little place where I could sit, close my eyes and imagine, until I felt very relaxed just like hypnosis" (Bliss, 1980, p. 1392).

How Are Dissociative Disorders Treated? As you have seen, people with dissociative amnesia and fugue often recover on their own. Only sometimes do their memory problems linger and require treatment. In con- trast, people with dissociative identity disorder usually require treatment to regain their lost memories and develop an integrated personality.Treatments for dissociative amnesia and fugue tend to be more successful than those for dissociative identity disorder, prob- ably because the former disorders are less complex.

How Do Ther pists Help People with Dissociative Amnesia and Fugue? The leading treatments for dissociative amnesia and fugue are psychodynamic therapy, hypnotic therapy, and drug therapy, although support for these interventions comes largely from. case studies rather than controlled investigations (Maldonado & Spiegel, 2003). Psychodynamic therapists guide patients with these disorders to search their unconscious in the hope of bringing forgotten experiences back to consciousness (Bartholomew, 2000; Loewenstein, 1991). The focus of psychodynamic therapy seems particularly well suited to the needs of people with these disorders. After all, the patients need to recover lost memories, and the general approach of psychodynamic therapists is to try to uncover memories—as well as other psychological processes—that have been repressed.Thus many theorists, including some who do not ordinarily favor psychody- namic approaches, believe that psychodynamic therapy may be the most appropriate treatment for these disorders.

Another common treatment for dissociative amnesia and fugue is hypnotic therapy, or hypnotherapy (see Table 6-6 on the next page). Therapists hypnotize patients and then guide them to recall forgotten events (Degun-Mather, 2002). Given the possibility that dissociative amnesia and fugue may each be a form of self-hypnosis, hypnotherapy

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Some Myths about Hypnosis

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It has something to do with a sleeplike state. Hypnotized subjects are fully awake.

1 88 :// CHAPTER 6

may be a particularly useful intervention. It has been applied both alone and in com- bination with other approaches.

Sometimes intravenous injections of barbiturates such as sodium amobarbital (Amytal) or sodium pentobarbital (Pentothal) are used to help patients with dissociative amnesia and fugue regain lost memories. These drugs are often called "truth serums," but the key to their success is their ability to calm people and free their inhibitions, thus helping them to recall anxiety-producing events (Fraser, 1993; Kluft, 1988).These drugs do not always work, however, and if used at all, they are likely to be combined with other treatment approaches (Spiegel, 1994).

How Do Therapists Help Individuals with Dissociative Identity Disorder? Unlike victims of amnesia and fugue, people with dissociative identity disorder do not typically recover without treatment (Maldonado & Spiegel, 2003; Spiegel, 1994).Treat- ment for this pattern is complex and difficult, much like the disorder itself. Therapists usually try to help the clients (1) recognize fully the nature of their disorder, (2) recover the gaps in their memory, and (3) integrate their subpersonalities into one functional personality (North &Yutzy, 2005; Kihlstrom, 2001).

RECOGNIZING THE DISORDER Once a diagnosis of dissociative identity disorder is made, therapists typically try to bond with the primary personality and with each of the sub- personalities (Kluft, 1999, 1992).As bonds are formed, therapists try to educate patients and help them to recognize fully the nature of their disorder (Krakauer, 2001; Allen, 1993). Some therapists actually introduce the subpersonalities to one another under

hypnosis, and some have patients look at video- tapes of their other personalities (Ross & Gahan, 1988; Sakheim et al., 1988). Many therapists have also found that group therapy helps to educate pa- tients (Fine & Madden, 2000). In addition, family therapy may be used to help educate spouses and children about the disorder and to gather helpful information about the patient (Kluft, 2001, 2000).

RECOVERING MEMORIES To help patients recover the missing pieces of their past, therapists use many of the approaches applied in other dissociative disor- ders, including psychodynamic therapy, hypnother- apy, and drug treatment (Kluft, 2001, 1991, 1985). These techniques work slowly for patients with dissociative identity disorder, as some subpersonali- ties may keep denying experiences that the others recall (Lyon, 1992). One of the subpersonalities

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Dissociative Disorders

People with dissociative disorders experience major changes in memory and iden- tity that are not caused by clear physical factors. People with dissociative amnesia are suddenly unable to recall important personal information or post events in their lives. Those with dissociative fugue not only fail to remember their personal identities but also flee to a different location and may establish a new identity. In dissociative identity disorder (multiple personality disorder), people display two or more distinct subpersonalities. The number of people diagnosed with dissociative identity disor- der has increased in recent years.

The dissociative disorders are not well understood. Among the processes that have been cited to explain them are extreme repression, operant conditioning, state- dependent learning, and self-hypnosis. The latter two phenomena, in particular, have excited the interest of clinical scientists.

Dissociative amnesia and fugue may end on their own or may require treat- ment. Dissociative identity disorder typically requires treatment. Approaches com- monly used to help people with dissociative amnesia and fugue recover their lost memories are psychodynamic therapy, hypnotic therapy, and sodium amoborbital or sodium pentobarbital. Therapists who treat people with dissociative identity disor- der use the same approaches but further focus on trying to help the clients recognize the scope of their disorder, recover the gaps in their memory, and integrate their subpersonalities into one functional personality.

Sornotoform and Dissociative Disorders :1/ 1 89

may even assume a "protector" role to prevent the primary personality from suffering the pain of recollecting traumatic experiences.

INTEGRATING THE SUBPERSONALITIES The final goal of therapy is to merge the different subpersonalities into a single, integrated identity. Integration is a continuous process that occurs throughout treatment until patients "own" all of their behaviors, emotions, sensations, and knowledge. Fusion is the final merging of two or more subpersonali- ties. Many patients distrust this final treatment goal, and their subpersonalities may see integration as a form of death (Kluft, 2001, 1999, 1991).Therapists have used a range of approaches to help merge subpersonalities, including psychodynamic, supportive, cogni- tive, and drug therapies (Goldman, 1995; Fichtner et al., 1990).

Once the subpersonalities are integrated, further therapy is typically needed to main- tain the complete personality and to teach social and coping skills that may help prevent later dissociations. In case reports, some therapists note high success rates (Rothschild, 2009; Coons & Bowman, 2001), but others find that patients continue to resist full in- tegration. A few therapists have in fact questioned the need for full integration.

PUTTING IT... together Disorders Rediscovered Somatoform and dissociative disorders are among the clinical field's earliest identified psychological disorders. Indeed, as you read in Chapter 1, they were key to the develop- ment of the psychogenic perspective. Despite this early impact, the clinical field stopped paying much attention to these disorders during the middle part of the twentieth cen- tury. The feeling among many clinical theorists was that the number of such cases was shrinking. And more than a few questioned the legitimacy of the diagnoses.

Much of that thinking has changed in the past two decades.The field's keen interest in the impact of stress upon health and physical illness has, by association, reawakened interest in sornatoform disorders. Similarly, as you will see in Chapter 15, the field has

efusionoThe final merging of two or more subpersonalities in multiple person- ality disorder.

THOUPTHTS/// 1. Why do the terms "hysteria" and

"hysterical" currently have such nega- tive connotations in our society, as in "mass hysteria" and "hysterical per- sonality"? pp. 164- 169

2. If parents who harm their chil- dren are clearly disturbed, as in cases of Munchausen syndrome by proxy, how should society react to them? Which is more

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greatly intensified its efforts to understand and treat Alzheimer's disease in recent years, and that work has sparked a broad interest in the operation of -memory, including an interest in dissociative disorders.

Over the past 25 years there has been an explosion of research seeking to help cli- nicians recognize, understand, and treat unexplained physical and memory disorders. Although this research has yet to produce clear insights or highly effective treatments, it has already suggested that the disorders may be more common than clinical theorists had come to believe. Moreover, there isgrowing evidence that the disorders may be rooted in processes that are already well known from other areas of study, such as overattentive- ness to bodily processes, cognitive misinterpretations, state-dependent learning, and self- hypnosis. Given this new wave of research enthusiasm, we may witness significant growth in our understanding and treatment of these disorders in the coming years.

At the same time, many of today's clinicians worry that the focus on somatoform and dissociative disorders is swinging back too far—that the high degree of interest in them may be creating a false impression of their prevalence or importance (Pope et al., 2007; Piper & Merskey, 2004). Some clinicians note, for example, that physicians are often quick to assign the label "somatoform" to elusive medical problems such as chronic fatigue syndrome and lupus—clearly a disservice to patients with such severe problems and to the progress of medical science. Similarly, a number of clinicians worry that at least some of the many legal defenses based on dissociative identity disorder or other dissociative disorders are contrived or inaccurate. Of course, such possibilities serve to highlight even further the importance of continued investigations into all aspects of the disorders.

appropriate — treatment or punish- and fugue are listed in DSM-IV-TR, ment? p. 168

many people greet such explanations

3. How might a culture help create with skepticism. Why? pp. 176- 181

cases of body dysmorphic disorder?

5 Some accused criminals claim that pp. 169- 173

they have dissociative identity dis-

4. Periodically we hear in the news about missing individuals who show up suddenly, claiming to have lost their memories while away. Although disorders such as dissociative amnesia

what would be an appropriate verdict? pp. 181-187

order and that their crimes were committed by one of their subperson- alities. If such claims are accurate,

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:\\■ KEY TEPIS/w: off-: s matoform disorder, p. 164

1:1 hysterical somatoform disorders, p. 164 conversion disorder, p. 164

somatization disorder, p. 166

pain disorder associated with psychological factors, p. 167

.4, malingering, p. 167

factitious disorder, p. 167

Munchausen syndrome, p. 168

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preoccupation somatoform disorders, p. 169

hypochondriasis, p. 169

body dysmorphic disorder, p. 169

Electra complex, p. 171

primary gain, p. 172

secondary gain, p. 172

placebo, p. 173

memory, p. 176

dissociative disorders, p. 176

dissociative amnesia, p. 178 %tett ,.

amnestic episode, p. 179

dissociative fugue, p. 180

dissociative identity disorder, p. 182

subpersonalities, p. 182

iatrogenic disorder, p. 184

repression, p. 184

state -dependent learning, p. 186

self-hypnosis, p. 186

hypnotic therapy, p. 187

fusion, p. 189

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