Transcript FAP7eLecture_Ch08_Somatic Disorders

Disorders Featuring
Somatic Symptoms
Chapter 8
Slides & Handouts by Karen Clay Rhines, Ph.D.
Comer, Fundamentals of
Abnormal Psychology, 7e
Disorders Featuring Somatic
Symptoms

Psychological factors may contribute to somatic,
or bodily, illnesses in a variety of ways

The idea that stress and related psychosocial
factors may contribute to physical illnesses has
ancient roots, yet it had few proponents before
the 20th century
Comer, Fundamentals of Abnormal
Psychology, 7e
2
Disorders Featuring Somatic
Symptoms

Over the course of the 20th century,
however, numerous studies convinced
medical and clinical researchers that
psychological factors, such as stress, worry,
and perhaps even unconscious needs, can
contribute to bodily illness

DSM-5 lists a number of disorders in which
bodily symptoms or concerns are the
primary features
Comer, Fundamentals of Abnormal
Psychology, 7e
3
Factitious Disorder

Sometimes when physicians cannot find a
medical cause for a patient’s symptoms, he or
she may suspect other factors are involved.

Patients may malinger, intentionally fake illness to
achieve external gain (e.g., financial
compensation, military deferment)

Patients may be manifesting a factitious disorder intentionally producing or faking symptoms
simply out of a wish to be a patient
Comer, Fundamentals of Abnormal
Psychology, 7e
4
Factitious Disorder

Known popularly as Munchausen syndrom,
people with a factitious disorder often go to
extremes to create the appearance of illness

Many secretly give themselves medications to
produce symptoms

Patients often research their supposed
ailments and are impressively knowledgeable
about medicine
Comer, Fundamentals of Abnormal
Psychology, 7e
5
Factitious Disorder

Clinical researchers have a hard time
determining the prevalence of this disorder
as patients hide the true nature of their
problem

Overall, the pattern appears to be more
common in women than men and the disorder
usually begins during early adulthood
Comer, Fundamentals of Abnormal
Psychology, 7e
6
Factitious Disorder

Factitious disorder seems to be particularly
common among people who (a) received
extensive medical treatment as children,
(2) carry a grudge against the medical
profession, or (3) have worked as a nurse,
lab technician, or medical aide
Comer, Fundamentals of Abnormal
Psychology, 7e
7
Factitious Disorder

The precise causes of factitious disorder are
not understood, although clinical reports
have pointed to factors such as depression
unsupportive parental relationships, and an
extreme need for social support
Comer, Fundamentals of Abnormal
Psychology, 7e
8
Factitious Disorder

Psychotherapists and medical practitioners
often become angry at people with a
factitious disorder, feeling that they are
wasting their time

People with the disorder, however, feel they
have no control over their problems and often
experience great distress
Comer, Fundamentals of Abnormal
Psychology, 7e
9
Factitious Disorder

In a related pattern, factitious disorder
imposed on another, known popularly as
Munchausen syndrome by proxy, parents
make up or produce physical illnesses in
their children
Comer, Fundamentals of Abnormal
Psychology, 7e
10
Conversion Disorder and
Somatic Symptom Disorder

When a bodily ailment has an excessive
and disproportionate impact on the
individual, no apparent medical cause, or is
inconsistent with known medical diseases,
doctors may suspect a conversion disorder
or somatic symptom disorder
Comer, Fundamentals of Abnormal
Psychology, 7e
11
Conversion Disorder

Conversion disorder

People with this disorder display physical
symptoms that affect voluntary motor or
sensory functioning, but the symptoms are
inconsistent with known medical diseases

In short, the individuals experience neurologicallike symptoms – blindness, paralysis, or loss of
feeling – that have no neurological basis
Comer, Fundamentals of Abnormal
Psychology, 7e
12
Conversion Disorder

Conversion disorder often is hard to
distinguish from genuine medical problems


It is always possible that a diagnosis of conversion
disorder is a mistake and the patient’s problem has
an undetected medical cause
Physicians sometimes rely on oddities in the
patient’s medical picture to help distinguish
the two

For example, conversion symptoms may be at odds with
the known functioning of the nervous system, as in cases
of glove anesthesia
Comer, Fundamentals of Abnormal
Psychology, 7e
13
Comer, Fundamentals of
Abnormal Psychology, 7e
14
Conversion Disorder

Unlike people with factitious disorder,
those with conversion disorder don’t
consciously want or produce their
symptoms

This pattern is called “conversion” disorder
because clinical theorists used to believe that
individuals with the disorders are converting
psychological needs into neurological
symptoms
Comer, Fundamentals of Abnormal
Psychology, 7e
15
Conversion Disorder

Conversion disorder usually begins
between late childhood and young
adulthood

It is diagnosed in women twice as often as in
men

It typically appears suddenly, at times of stress

It is thought to be rare, occurring in at most 5
of every 1,000 persons
Comer, Fundamentals of Abnormal
Psychology, 7e
16
Somatic Symptom Disorder

People with somatic symptom disorder
become excessive distressed, concerned,
and anxious about bodily symptoms that
they are experiencing

Two patterns of somatic symptom disorder
have received particular attention:

Somatization pattern

Predominant pain pattern
Comer, Fundamentals of Abnormal
Psychology, 7e
17
Somatic Symptom Disorder

People with a somatization pattern experience
many long-lasting physical ailments that have
little or no organic basis


Also known as Briquet’s syndrome
A sufferer’s ailments often include pain
symptoms, gastrointestinal symptoms, sexual
symptoms, and neurological symptoms

Patients usually go from doctor to doctor in search
of relief
Comer, Fundamentals of Abnormal
Psychology, 7e
18
Somatic Symptom Disorder

Somatization pattern

Patients with this pattern often describe their
symptoms in dramatic and exaggerated terms

Most also feel anxious and depressed

The pattern typically lasts for many years

Symptoms may fluctuate over time but rarely
disappear completely without therapy
Comer, Fundamentals of Abnormal
Psychology, 7e
19
Somatic Symptom Disorder

Somatization pattern

Between 0.2% and 2% of all women in the U.S.
experience a somatization pattern in any given
year (compared with less than 0.2% of men)

The pattern often runs in families and begins
between adolescence and young adulthood
Comer, Fundamentals of Abnormal
Psychology, 7e
20
Somatic Symptom Disorder

Predominant pain pattern


If the primary feature of somatic symptom
disorder is pain, the individual is said to have a
predominant pain pattern
Although the precise prevalence has not been
determined, this pattern appears to be fairly
common


The pattern often develops after an accident or illness
that has caused genuine pain
The pattern may begin at any age, and more
women than men seem to experience it
Comer, Fundamentals of Abnormal
Psychology, 7e
21
What Causes Conversion and
Somatic Symptom Disorder?

For many years, conversion and somatic symptom
disorders were referred to as hysterical disorders


This label was to convey the prevailing belief that
excessive and uncontrolled emotions underlie the
bodily symptoms
Today’s leading explanations come from the
psychodynamic, behavioral, cognitive, and
multicultural models

None has received much research support, and the
disorders are still poorly understood
Comer, Fundamentals of Abnormal
Psychology, 7e
22
What Causes Conversion and
Somatic Symptom Disorder?

The psychodynamic view

Freud believed that hysterical disorders
represented a conversion of underlying
emotional conflicts into physical symptoms

Because most of his patients were women,
Freud centered his explanation on the
psychosexual development of girls and focused
on the phallic stage of development (ages 3 to
5)…
Comer, Fundamentals of Abnormal
Psychology, 7e
23
What Causes Conversion and
Somatic Symptom Disorder?

The psychodynamic view




During this stage, Freud believed that girls develop a
pattern of sexual desires for their fathers (the Electra
complex) and recognize that they must compete with their
mothers for his attention
Because of the mother’s more powerful position, however,
girls repress these sexual feelings
Freud believed that if parents overreact to such feelings, the
Electra complex would remain unresolved and the child
might re-experience sexual anxiety throughout her life
Freud concluded that some women unconsciously hide
their sexual feelings in adulthood by converting them into
physical symptoms
Comer, Fundamentals of Abnormal
Psychology, 7e
24
What Causes Conversion and
Somatic Symptom Disorder?

The psychodynamic view

Today’s psychodynamic theorists take issues
with Freud’s explanation of the Electra conflict

They continue to believe that sufferers of these
disorders have unconscious conflicts carried from
childhood
Comer, Fundamentals of Abnormal
Psychology, 7e
25
What Causes Conversion and
Somatic Symptom Disorder?

The psychodynamic view

Psychodynamic theorists propose that two
mechanisms are at work in hysterical
disorders:

Primary gain: bodily symptoms keep internal
conflicts out of conscious awareness

Secondary gain: bodily symptoms further enable
people to avoid unpleasant activities or receive
sympathy from others
Comer, Fundamentals of Abnormal
Psychology, 7e
26
What Causes Conversion and
Somatic Symptom Disorder?

The behavioral view

Behavioral theorists propose that the physical
symptoms of hysterical disorders bring rewards to
sufferers




May remove individual from an unpleasant situation
May bring attention from other people
In response to such rewards, people learn to display
symptoms more and more
This focus on rewards is similar to the psychodynamic
idea of secondary gain, but behaviorists view the gains
as the primary cause of the development of the
disorder
Comer, Fundamentals of Abnormal
Psychology, 7e
27
What Causes Conversion and
Somatic Symptom Disorder?

The cognitive view

Some cognitive theorists propose that
conversion and somatic symptom disorders are
forms of communication, providing a means for
people to express difficult emotions

Like psychodynamic theorists, cognitive theorists
hold that emotions are being converted into
physical symptoms

This conversion is not to defend against anxiety but to
communicate extreme feelings
Comer, Fundamentals of Abnormal
Psychology, 7e
28
What Causes Conversion and
Somatic Symptom Disorder?

The multicultural view

Some theorists believe that Western clinicians
hold a bias that sees somatic symptoms as an
inferior way of dealing with emotions


The transformation of personal distress into somatic
complaints is the norm is many
non-Western cultures
The lesson to be learned from multicultural
findings is that both bodily and psychological
reactions to life events are often influenced by
one’s culture
Comer, Fundamentals of Abnormal
Psychology, 7e
29
How Are Conversion and Somatic
Symptom Disorders Treated?

People with conversion and somatic
symptom disorders usually seek
psychotherapy only as a last resort

They believe their problems are completely
medical
Comer, Fundamentals of Abnormal
Psychology, 7e
30
How Are Conversion and Somatic
Symptom Disorders Treated?

Many therapists focus on the causes of the
disorders and apply techniques including:

Insight – often psychodynamically oriented

Exposure – client thinks about traumatic
event(s) that triggered the physical symptoms

Drug therapy – especially antianxiety and
antidepressant medication
Comer, Fundamentals of Abnormal
Psychology, 7e
31
How Are Conversion and Somatic
Symptom Disorders Treated?

Other therapists try to address the physical
symptoms of these disorders, applying techniques
such as:




Suggestion – usually an offering of emotional support
that may include hypnosis
Reinforcement – a behavioral attempt to change
reward structures
Confrontation – an overt attempt to force patients out
of the sick role
Researchers have not fully evaluated the effects of
these particular approaches on these disorders
Comer, Fundamentals of Abnormal
Psychology, 7e
32
Illness Anxiety Disorder

People with illness anxiety disorder,
previously known as hypochondriasis,
experience chronic anxiety about their
health and are concerned that they are
developing a serious medical illness,
despite the absence of somatic symptoms
Comer, Fundamentals of Abnormal
Psychology, 7e
33
Illness Anxiety Disorder

They repeatedly check their bodies for
signs of illness and misinterpret bodily
symptoms as signs of a serious illness


Often their symptoms are merely normal bodily
changes, such as occasional coughing, sores, or
sweating
Although some patients recognize that their
concerns are excessive, many do not
Comer, Fundamentals of Abnormal
Psychology, 7e
34
Illness Anxiety Disorder

Although this disorder can begin at any
age, it starts most often in early adulthood,
among men and women in equal numbers

Between 1% and 5% of all people experience
the disorder

For most patients, symptoms rise and fall over
the years
Comer, Fundamentals of Abnormal
Psychology, 7e
35
Illness Anxiety Disorder

Theorists explain this disorder much as
they explain various anxiety disorders:

Behaviorists: classical conditioning or
modeling

Cognitive theorists: oversensitivity to bodily
cues
Comer, Fundamentals of Abnormal
Psychology, 7e
36
Illness Anxiety Disorder

Individuals with illness anxiety disorder
typically receive the kinds of treatments
applied to OCD:

Antidepressant medication

Exposure and response prevention (ERP)

Cognitive-behavioral therapies
Comer, Fundamentals of
Abnormal Psychology, 7e
37
Psychophysiological Disorders:
Psychological Factors Affecting Medical Condition

About 85 years ago, clinicians first identified a
group of physical illnesses that seemed to
result from an interaction of biological,
psychological, and sociocultural factors

Early versions of the DSM labeled these
illnesses psychophysiological, or
psychosomatic, disorders

DSM-5 labels them as psychological factors
affecting medical condition
Comer, Fundamentals of Abnormal
Psychology, 7e
38
Psychophysiological Disorders:
Psychological Factors Affecting Medical Condition

It is important to recognize that these
psychophysiological disorders bring about
actual physical damage

They are different from the factitious,
conversion, somatic symptom, and illness
anxiety disorders that are accounted for
primarily by psychological factors
Comer, Fundamentals of Abnormal
Psychology, 7e
39
Traditional Psychophysiological
Disorders

Before the 1970s, the best known and most
common of the psychophysiological disorders
were ulcers, asthma, insomnia, chronic
headaches, high blood pressure, and coronary
heart disease

Recent research has shown that many other
physical illnesses may also be caused by an
interaction of psychosocial and physical factors
Comer, Fundamentals of Abnormal
Psychology, 7e
40
Traditional Psychophysiological
Disorders

Ulcers



Lesions in the wall of the stomach that result in
burning sensations or pain, vomiting, and stomach
bleeding
Experienced by over 25 million people at some point in
their lives
Causal psychosocial factors:


Environmental pressures, intense feelings of anger or anxiety
Causal physiological factors:

Bacterial infection
Comer, Fundamentals of Abnormal
Psychology, 7e
41
Traditional Psychophysiological
Disorders

Asthma

A narrowing of the body’s airways that makes breathing difficult

Affects up to 25 million people in the U.S. each year


Causal psychosocial factors:


Most victims are children or young teens at the time of first attack
Environmental pressures or anxiety
Causal physiological factors:

Allergies, a slow-acting sympathetic nervous system, weakened
respiratory system
Comer, Fundamentals of Abnormal
Psychology, 7e
42
Traditional Psychophysiological
Disorders

Insomnia

Difficulty falling asleep or maintaining sleep

Affects 10% of people in the U.S. each year

Causal psychosocial factors:


High levels of anxiety or depression
Causal physiological factors:

Overactive arousal system, certain medical ailments
Comer, Fundamentals of Abnormal
Psychology, 7e
43
Traditional Psychophysiological
Disorders

Chronic headaches


Frequent intense aches of the head or neck that are not caused by
another physical disorder

Tension headaches affect 45 million Americans each year

Migraine headaches affect 23 million Americans each year
Causal psychosocial factors:


Environmental pressures; general feelings of helplessness, anger,
anxiety, depression
Causal physiological factors:

Abnormal serotonin activity, vascular problems, muscle weakness
Comer, Fundamentals of Abnormal
Psychology, 7e
44
Traditional Psychophysiological
Disorders

Hypertension



Chronic high blood pressure, usually producing few
outward symptoms
Affects 75 million Americans each year
Causal psychosocial factors:


Constant stress, environmental danger, general feelings of
anger or depression
Causal physiological factors:


10% caused by physiological factors alone
Obesity, smoking, poor kidney function, high proportion of
collagen (rather than elastic) tissue in an individual’s blood
vessels
Comer, Fundamentals of Abnormal
Psychology, 7e
45
Traditional Psychophysiological
Disorders

Coronary heart disease



Caused by blockage in the coronary arteries
The term refers to several problems, including myocardial
infarction (heart attack)
Nearly 18 million people in the US suffer from some form of
coronary heart disease


Causal psychosocial factors:


It is the leading cause of death in men older than 35 years and women
older than 40
Job stress, high levels of anger or depression
Causal physiological factors:

High level of cholesterol, obesity, hypertension, the effects of smoking,
lack of exercise
Comer, Fundamentals of Abnormal
Psychology, 7e
46
What Factors Contribute to
Psychophysiological Disorders?

A number of variables contribute to the
development of psychophysiological
disorders, including:

Biological factors

Psychological factors

Sociocultural factors
Comer, Fundamentals of Abnormal
Psychology, 7e
47
What Factors Contribute to
Psychophysiological Disorders?

Biological factors

Defects in the autonomic nervous system
(ANS) are believed to contribute to the
development of psychophysiological disorders

Other more specific biological problems may
also contribute

For example, a weak gastrointestinal system may
create a predisposition to developing ulcers
Comer, Fundamentals of Abnormal
Psychology, 7e
48
What Factors Contribute to
Psychophysiological Disorders?

Psychological factors

According to many theorists, certain needs,
attitudes, emotions, or coping styles may cause
people to overreact repeatedly to stressors –
increasing their chances of developing
psychophysiological disorders

Examples: a repressive coping style, a Type A
personality style, feelings of hostility and time
urgency
Comer, Fundamentals of Abnormal
Psychology, 7e
49
What Factors Contribute to
Psychophysiological Disorders?

Sociocultural factors

Adverse social conditions may set the stage for
psychophysiological disorders

One of society’s most adverse social conditions is
poverty

Research also reveals that belonging to an ethnic or
cultural minority group increases the risk of
developing these disorders and other health
problems, but the relationship is complicated
Comer, Fundamentals of Abnormal
Psychology, 7e
50
New Psychophysiological
Disorders

Clearly, biological, psychological, and
sociocultural variables combine to produce
psychophysiological disorders

In fact, the interaction of psychosocial and
physical factors is now considered the rule of
bodily function, not the exception

In recent years, more and more illnesses have
been added to the list of psychophysiological
disorders
Comer, Fundamentals of Abnormal
Psychology, 7e
51
New Psychophysiological Disorders

Are physical illnesses related to stress?

The development of the Social Adjustment
Rating Scale in 1967 enabled researchers to
examine the relationship between life stress
and the onset of illness
Comer, Fundamentals of Abnormal
Psychology, 7e
52
Comer, Fundamentals of Abnormal
Psychology, 7e
53
New Psychophysiological Disorders

Are physical illnesses related to stress?

Using the Social Adjustment Rating Scale, studies have
linked stressors of various kinds to a wide range of
physical conditions

Overall, the greater the amount of life stress, the
greater the likelihood of illness

Researchers have even found a relationship between traumatic
stress and death
Comer, Fundamentals of Abnormal
Psychology, 7e
54
New Psychophysiological Disorders

Are physical illnesses related to stress?

One shortcoming of the Social Adjustment
Rating Scale is that it does not take into
consideration the particular stress reactions
within specific populations

For example, members of minority groups may
respond to stress differently and women and men
have been shown to react differently to certain life
changes measured by the scale
Comer, Fundamentals of Abnormal
Psychology, 7e
55
Psychoneuroimmunology

Researchers have increasingly looked to the
body’s immune system as the key to the
relationship between stress and infection

This area of study is called
psychoneuroimmunology
Comer, Fundamentals of Abnormal
Psychology, 7e
56
Psychoneuroimmunology

The immune system is the body’s network of
activities and cells that identify and destroy
antigens (foreign invaders, such as bacteria)
and cancer cells

Among the most important cells in this system are
the lymphocytes


Lymphocytes are white blood cells that circulate through
the lymph system and the bloodstream, attacking
invaders
Lymphocytes include helper T-cells, natural killer Tcells, and B-cells
Comer, Fundamentals of Abnormal
Psychology, 7e
57
Psychoneuroimmunology

Researchers now believe that stress can
interfere with the activity of lymphocytes,
slowing them down and increasing a person’s
susceptibility to viral and bacterial infections

Several factors influence whether stress will
result in a slowdown of the system, including
biochemical activity, behavioral changes,
personality style, and degree of social support
Comer, Fundamentals of Abnormal
Psychology, 7e
58
Psychoneuroimmunology

Biochemical activity

Stress leads to increased activity by the sympathetic
nervous system, including a release of norepinephrine


In addition to supporting nervous system activity, this
chemical also appears to slow down the functioning of the
immune system
Similarly, the body’s endocrine glands reduce immune
system functioning during periods of prolonged stress
through the release of corticosteroids

In addition, corticosteroids also trigger increased cytokines,
which lead to chronic inflammation
Comer, Fundamentals of Abnormal
Psychology, 7e
59
Psychoneuroimmunology

Behavioral changes


Stress may set in motion a series of behavioral
changes – poor sleep patterns, poor eating, lack of
exercise, increase in smoking and/or drinking –
that indirectly affect the immune system
Personality style

An individual’s personality style (including their
level of optimism, constructive coping strategies,
and resilience) experience better immune system
functioning and are better prepared to fight off
illness
Comer, Fundamentals of Abnormal
Psychology, 7e
60
Psychoneuroimmunology

Social support

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

Studies have found that social support and
affiliation with others may actually protect
people from stress, poor immune system
functioning, and subsequent illness, and can
help speed up recovery from illness or surgery
Comer, Fundamentals of Abnormal
Psychology, 7e
61
Psychological Treatments for
Physical Disorders

As clinicians have discovered that stress and
related psychosocial factors may contribute to
physical disorders, they have applied
psychological treatment to more and more
medical problems

The most common of these interventions are
relaxation training, biofeedback training, meditation,
hypnosis, cognitive interventions, support groups, and
therapies designed to increase awareness and
expression of emotion
Comer, Fundamentals of Abnormal
Psychology, 7e
62
Psychological Treatments for
Physical Disorders

The field of treatment that combines
psychological and physical interventions to
treat or prevent medical problems is known
as behavioral medicine
Comer, Fundamentals of Abnormal
Psychology, 7e
63
Psychological Treatments for
Physical Disorders

Relaxation training


People can be trained to relax their muscles at will,
a process that sometimes reduces feelings of
anxiety
Relaxation training can help prevent or treat
medical illnesses that are related to stress


Often used in conjunction with medication in the
treatment of high blood pressure
Often used alone to treat chronic headaches, insomnia,
asthma, pain after surgery, certain vascular diseases, and
the undesirable effects of cancer treatments
Comer, Fundamentals of Abnormal
Psychology, 7e
64
Psychological Treatments for
Physical Disorders

Biofeedback

Patients given biofeedback training are connected
to machinery that gives them continuous readings
about their involuntary bodily activities

Somewhat helpful in the treatment of anxiety disorders,
this procedure has been used successfully to treat
headaches and muscular disabilities caused by stroke or
accident

Some biofeedback training has been effective in the
treatment of heartbeat irregularities, asthma, migraine
headaches, high blood pressure, stuttering, and pain
Comer, Fundamentals of Abnormal
Psychology, 7e
65
Psychological Treatments for
Physical Disorders

Meditation

Although meditation has been practiced since
ancient times, Western health care professionals
have only recently become aware of its
effectiveness in relieving physical distress

Meditation is a technique of turning one’s
concentration inward and achieving a slightly
changed state of consciousness

Meditation has been used to manage pain, treat high
blood pressure, heart problems, insomnia, and asthma
Comer, Fundamentals of Abnormal
Psychology, 7e
66
Psychological Treatments for
Physical Disorders

Hypnosis

Individuals who undergo hypnosis are guided
into a sleeplike, suggestible state during which
they can be directed to act in unusual ways, to
remember unusual sensations, or to forget
remembered events

With training, hypnosis can be done without a
hypnotist (self-hypnosis)
Comer, Fundamentals of Abnormal
Psychology, 7e
67
Psychological Treatments for
Physical Disorders

Hypnosis

This technique seems to be particularly helpful
in the control of pain; is now used to treat such
problems as skin diseases, asthma, insomnia,
high blood pressure, warts, and other forms of
infection
Comer, Fundamentals of Abnormal
Psychology, 7e
68
Psychological Treatments for
Physical Disorders

Cognitive interventions

People with physical ailments have sometimes
been taught new attitudes or cognitive
responses as part of treatment

One intervention is stress inoculation training, in
which patients are taught to rid themselves of
negative self-statements and to replace these with
coping self-statements
Comer, Fundamentals of Abnormal
Psychology, 7e
69
Psychological Treatments for
Physical Disorders

Support groups and emotion expression

If negative psychological symptoms (e.g.,
depression, anxiety) contribute to a person’s
physical ills, intervention to reduce these
emotions should help reduce the ills

These techniques have been used to treat a
variety of illnesses including HIV, asthma,
cancer, headache, and arthritis
Comer, Fundamentals of Abnormal
Psychology, 7e
70
Psychological Treatments for
Physical Disorders

Combination approaches

Studies have found that the various
psychological interventions for physical
problems tend to be equal in effectiveness

Psychological treatments are often of greatest help
when they are combined and used with medical
treatment
Comer, Fundamentals of Abnormal
Psychology, 7e
71