Transcript Ch08SomaticDisordersx

chapter eight
Disorders Featuring
Somatic Symptoms
Disorders Featuring Somatic Symptoms
• Psychological factors contribute to somatic
illnesses in a variety of ways
• The idea that stress and related
psychosocial factors may contribute to
physical illnesses
– Has ancient roots but few proponents before
the twentieth century
– Now represented in numerous studies within
the twentieth century and beyond
Factitious Disorder
• DSM-5 lists disorders in which bodily symptoms
or concerns are the primary features of the
disorder
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Factitious disorder
Conversion disorder
Somatic symptom disorder
Illness anxiety disorder
Psychological factors
Factitious Disorder
•
People with a factitious disorder
(known popularly as
MUNCHAUSEN SYNDROME)
Dx Checklist
• Factitious Disorder Imposed on
Self
1.
– Prevalence difficult to determine;
more common in women, and
likely to occur in early adulthood
2.
•
False creation of physical or
psychological symptoms, or
deceptive production of injury or
disease, even without external
rewards for such ailments
Presentation of oneself as ill,
damaged, or hurt
Factitious Disorder Imposed on
Another
1.
2.
False creation of physical or
psychological symptoms, or
deceptive production of injury or
disease, in another person, even
without external rewards for such
ailments
Presentation of another person
(victim) as ill, damaged, or hurt
Factitious Disorder
• Causes
– More common in certain groups of people
– Not understood, but reports point to depression,
unsupportive parental relationships, and extreme
need for social support
• Patients may frustrate health professionals; but
the disorder can cause great distress
PSYCH WATCH
Munchausen Syndrome by Proxy
• Caused by a caregiver who uses various techniques to induce
symptoms in a child
• Ends in death for between 6 and 30 percent of victims as a
result of symptoms; and in permanent disfigurement or physical
impairment for 8 percent
• Is difficult to diagnose; viewed as crime by law enforcement
• Involves mother who is emotionally needy; with little social
support outside medical system and most often denied
treatment
Conversion Disorder
• Conversion disorder
– Individuals experience
neurological-like
symptoms (e.g.,
blindness, paralysis, or
loss of feeling) that have
no neurological basis
Dx Checklist
• Conversion Disorder
1. Presence of at least
one symptom or deficit
that affects voluntary or
sensory function
2. Symptoms are found to
be inconsistent with
known neurological or
medical disease
3. Significant distress or
impairment
Conversion Disorder and Somatic Symptom
Disorder
• CONVERSION DISORDER or SOMATIC SYMPTOM
DISORDER
– Occurs when bodily ailment has an excessive and
disproportionate impact on the individual
– Has no apparent medical cause or is inconsistent with known
medical diseases
– Is not consciously wanted or purposely produced by patient
– Is difficult to distinguish from genuine medical problems
Glove Anesthesia
In this conversion symptom (left), the entire hand, extending from the fingertips to
the wrist, becomes numb
Actual physical damage (right) to the ulnar nerve, in contrast, causes anesthesia in
the ring finger and little finger, and beyond the wrist part way up the arm; damage to
the radial nerve causes loss of feeling only in parts of the ring, middle, and index
fingers and the thumb, and partway up the arm (Adapted from Gray, 1959.)
Somatic Symptom Disorder
 SOMATIC SYMPTOM DISORDER
 Occurs when people become excessively
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
Somatic Symptom Disorder
• SOMATIZATION PATTERN
– Involves people with many long-lasting
physical ailments that have little or no organic
basis
– Is also known as BRIQUET’S SYNDROME
– Patients usually go from doctor to doctor in
search of relief
– Pattern often runs in families
Somatic Symptom Disorder
Dx Checklist
Somatic Symptom Disorder
• Person experiences at least one upsetting or
repeatedly disruptive physical (somatic) symptom.
1.
Person experiences an unreasonable number of
thoughts, feelings, and behaviors regarding the nature or
implications of the physical symptoms, including one of
the following:
a)
b)
c)
2.
Repeated, excessive thoughts about their seriousness
Continual high anxiety about their nature or health
implications
Disproportionate amounts of time and energy spent on the
symptoms or their health implications
Physical symptoms usually continue to some degree for
more than 6 months.
Somatic Symptom Disorder
 Predominant pain pattern
 Occurs when the primary feature of somatic
symptom disorder is pain
 Although the precise prevalence has not been
determined, this pattern appears to be fairly
common
What Causes Conversion and Somatic
Symptom Disorder?
For many years, conversion and somatic symptom disorders
were referred to as HYSTERICAL disorders
No explanation has received much research support, and the
disorders are still poorly understood
Today’s leading explanations come from the psychodynamic,
behavioral, cognitive, and multicultural models
What Causes Conversion and Somatic
Symptom Disorder?
• Psychodynamic view: Freud
– Believed that hysterical disorders represented a
CONVERSION of underlying emotional conflicts
into physical symptoms
– Centered his explanation on the psychosexual
development of girls and focused on the
PHALLIC STAGE of development (ages 3 to 5)
– Concluded that some women unconsciously hide
their sexual feelings in adulthood by converting
them into physical symptoms
What Causes Conversion and Somatic
Symptom Disorder?
• Contemporary psychodynamic view
– Takes issue with Freud’s explanation of the
ELECTRA CONFLICT
– Continues to believe that sufferers of these
disorders have unconscious conflicts carried from
childhood
– Proposes that two mechanisms are involved in
hysterical disorders
• PRIMARY GAIN
• SECONDARY GAIN
What Causes Conversion and Somatic
Symptom Disorder?
 Behavioral view
 Proposes that the physical symptoms of
hysterical disorders bring REWARDS to
sufferers
 Suggests response to such rewards helps
people learn to increasingly display symptoms
 Views gains that come after underlying
conflict as the primary cause of the
development
What Causes Conversion and Somatic
Symptom Disorder?
 Cognitive view
 Proposes that conversion and somatic
symptom disorders are forms of
COMMUNICATION, providing a means for
people to express difficult emotions
 Holds that emotions are being converted into
physical symptoms; this conversion is not to
defend against anxiety but to communicate
extreme feelings
What Causes Conversion and Somatic
Symptom Disorder?
• 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 nonWestern cultures
– Both bodily and psychological reactions to life
events are often influenced by one’s culture
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
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 –
Behavioral attempt to
change reward structures
• CONFRONTATION – Overt
attempt to force patients out
of the sick role
The Positive Side of Swearing
• Famous English soccer
player Wayne Rooney
yells out in pain after
being struck by a ball in
the groin.
• Research indicates that
swearing can help reduce
pain, and not just pain on
display in conversion and
somatic symptom
disorders, but even pain
like Rooney’s (Stephens
et al., 2009)
Illness Anxiety Disorder
•
People with ILLNESS ANXIETY
DISORDER, previously known as
HYPOCHONDRIASIS
– Experience chronic anxiety about
their health
– Are concerned that they are
developing a serious medical illness,
despite the absence of somatic
symptoms
– Most often begins in early
adulthood; no gender differences
Dx Checklist
Illness Anxiety Disorder
1. Person is preoccupied with
thoughts about having or getting
a significant illness. In reality,
person has no or, at most, mild
somatic symptoms.
2. Person has easily triggered high
anxiety about health.
3. Person displays unduly high
number of health-related
behaviors (e.g., keeps focusing
on body) or dysfunctional
health-avoidance behaviors
(e.g., avoids doctors).
4. Person’s concerns continue to
some degree for at least 6
months.
Illness Anxiety Disorder
• Theoretical explanations
– Behaviorists: Classical conditioning or
modeling
– Cognitive theorists: Oversensitivity to bodily
cues
• Treatments
– Antidepressant medication
– Exposure and response prevention (ERP)
– Cognitive-behavioral therapies
Psychophysiological Disorders:
Psychological Factors Affecting Medical Condition
 Early versions of the
DSM labeled these
illnesses
psychophysiological, or
psychosomatic, disorders
 DSM-5 labels them as
PSYCHOLOGICAL
FACTORS AFFECTING
OTHER MEDICAL
CONDITIONS
Dx Checklist
Psychological Factors
Affecting Other Medical
Conditions
1. The presence of a medical
condition
2. Psychological factors
negatively affect the medical
condition by:
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Affecting the course of the
medical condition
Providing obstacles for the
treatment of the medical
condition
Posing new health risks
Triggering or worsening the
medical condition
Traditional Psychophysiological Disorders
• Before the 1970s
– Best known and most common of the
psychophysiological disorders were ulcers,
asthma, insomnia, chronic headaches, high
blood pressure, and coronary heart disease
• Recent research
– Many other physical illnesses may also be
caused by an interaction of psychosocial and
physical factors
Traditional Psychophysiological Disorders
• ULCERS
– Involves 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; psychological and physiological factors
• ASTHMA
– Is a narrowing of the body’s airways that makes
breathing difficult
– Affects up to 25 million people in the United States
each year; most victims are children or young teens
at the time of first attack; psychological and
physiological factors
Traditional Psychophysiological Disorders
• INSOMNIA
– Involves difficulty falling asleep or maintaining sleep
– Affects 10 percent of people in the United States each
year; psychological and physiological factors
• CHRONIC HEADACHES
– Involves 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; psychological and physiological factors
Migraine Headaches
• Are extremely severe,
often nearly paralyzing
• Are located on one side of
the head and are
sometimes accompanied
by dizziness, nausea, or
vomiting
MIGRAINE HEADACHES develop in two phases
(1) blood vessels in the brain narrow, so that the flow of blood to parts of the brain
is reduced, and
(2) the same blood vessels later expand, so that blood flows through them rapidly,
stimulating many neuron endings and causing pain
Traditional Psychophysiological Disorders
• HYPERTENSION
– Chronic high blood pressure, usually producing few
outward symptoms
– Affects 75 million Americans each year; psychological
and physiological factors
• CORONARY HEART DISEASE
– Caused by blockage in the coronary arteries; refers to
several problems, including myocardial infarction
(heart attack)
– Nearly 18 million people in the United States suffer
from some form of coronary heart disease; leading
cause of death for U.S. men and women;
psychological and physiological factors
Sleep-Wake Disorders
• DSM-5 identifies a number of sleep-wake
disorders: Dyssomnias and parasomnias
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INSOMNIA DISORDER
HYPERSOMNOLENCE DISORDER
NARCOLEPSY/HYPOCRETIN DEFICIENCY
SLEEP APNEA
CIRCADIAN RHYTHM SLEEP-WAKE DISORDER
NIGHTMARE DISORDER
DISORDER OF AROUSAL
What Factors Contribute to
Psychophysiological Disorders?
• A number of variables contribute to the
development of psychophysiological
disorders, including
– Biological factors
– Psychological factors
– Sociocultural factors
What Factors Contribute to
Psychophysiological Disorders?
Biological factors
Psychological factors
• Defects in the
AUTONOMIC
NERVOUS
SYSTEM (ANS)
contribute to the
development of
psychophysiological
disorders
• Certain needs,
attitudes, emotions,
or coping styles may
cause people to
overreact repeatedly
to stressors
• Other more specific
biological problems
may also contribute
• This increases
chances of
developing
psychophysiological
disorders
Sociocultural factors
• Poverty
• Ethnic or cultural
group membership
• Relationship among
factors is
complicated
How Much Discrimination Do Racial
Minority Teenagers Face?
• It depends on who’s
being asked the
question
• In a recent survey of
1,590 teenagers and
young adults, African
American respondents
were more likely than
white American
respondents to
recognize that African
American teens
experience various
forms of discrimination
(Black Youth Project,
2011)
New Psychophysiological Disorders
• Biological, psychological, and sociocultural
factors combine to produce
psychophysiological disorders
– Many links between psychosocial stress and
a wide range of physical illnesses
New Psychophysiological Disorders
• SOCIAL READJUSTMENT RATING SCALE
(Holmes and Rahe)
– Established in 1967 to examine the relationship
between life stress and the onset of illness
• Found LCU scores of sick people during the year
before they fell ill were much higher than those of
healthy people
• Greater the amount of life stress, the greater the
likelihood of illness
• Relationship between traumatic stress and death found
Most Stressful Life Events
Adult: Social Readjustment Rating Scale
1. Death of spouse
2. Divorce
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
What do you think?
What did undergraduate students report as
their top twelve sources of stress in the
USQ?
Research results found in Table 8-8 were
published in 1992. Do you think these have
changed since them?
New Psychophysiological Disorders
One shortcoming of Holmes and Rahe’s Social
Readjustment Rating is that it does not take into
consideration the particular life stress reactions of
specific populations
Prevalence of Medical Disorders Among U.S. Racial Groups
African
Americans
White
Americans
Hispanic
Americans
High Blood
Pressure
High
Cholesterol
Diabetes
Asthma
Cancer
42%
24%
16%
13%
5%
29%
30%
11%
11%
8%
21%
20%
11%
9%
3%
Psychoneuroimmunology
• PSYCHONEUROIMMUNOLOGY
– Involves study of the connection between
stress, the body’s immune system, and illness
• IMMUNE SYSTEM
– Is the body’s network of activities and cells
that identify and destroy ANTIGENS and
cancer cells
Psychoneuroimmunology
• Among the most important cells in this
system are the LYMPHOCYTES
– Are white blood cells that circulate through the
lymph system and the bloodstream, attacking
invaders
– Include helper T-CELLS, NATURAL KILLER
T-CELLS, and B-CELLS
How Do Lymphocytes Meet up with Invading
Antigens?
• The lymphocytes are
first alerted by
macrophages, big
white blood cells in the
immune system that
recognize an antigen,
engulf it, break it down,
and hand off its
dissected parts to the
lymphocytes
• Here a macrophage
stretches its long
“arms” (pseudopods) to
detect and capture the
suspected antigens
First line of defense
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
•
•
•
•
Biochemical activity
Behavioral changes
Personality style
Degree of social support
Psychoneuroimmunology:
Biochemical Activity
• Stress leads to
increased activity by
the sympathetic
nervous system,
including a release of
NOREPINEPHRINE
and a slowdown in
functioning of the
immune system
• The body’s endocrine
glands reduce immune
system functioning
during periods of
prolonged stress
through the release of
CORTICOSTEROIDS,
which also trigger
increased CYTOKINES
leading to chronic
inflammation
Psychoneuroimmunology: Behavioral
Changes and Personality Style
• 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
– Individual personality
style (including a
person’s level of
optimism,
constructive coping
strategies, and
resilience) may
experience better
immune system
functioning and are
better prepared to
fight off illness
Psychoneuroimmunology
 Social support
 Few social supports and loneliness are
related to poorer immune functioning in the
face of stress
 Social support and affiliation with others may
actually protect people from stress, poor
immune system functioning, subsequent
illness, and quicker recovery from illness or
surgery
Psychological Treatments for Physical
Disorders
• BEHAVIORAL
MEDICINE
– Is a treatment field that
combines
psychological and
physical interventions
to treat or prevent
medical problems
The power of distraction
Psychological Treatments for Physical
Disorders
• Most common of these treatments
– RELAXATION TRAINING
– BIOFEEDBACK TRAINING
– MEDITATION
– HYPNOSIS
Psychological Treatments for Physical
Disorders
• COGNITIVE INTERVENTIONS
– People with physical ailments have
sometimes been taught new attitudes or
cognitive responses as part of treatment
• STRESS INOCULATION TRAINING
Psychological Treatments for Physical
Disorders
• SUPPORT GROUPS AND EMOTION
EXPRESSION
– If negative psychological symptoms contribute to a
person’s physical ills, intervention to reduce these
emotions should help reduce the ills
– Techniques have been used to treat a variety of
illnesses including HIV, asthma, cancer, headache,
and arthritis
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
PUTTING IT…Together
• EXPANDING THE BOUNDARIES OF
ABNORMAL PSYCHOLOGY
– Just as physical factors have long been
recognized as playing a role in abnormal mental
functioning, psychological events are now
considered important contributors to abnormal
physical functioning
– The field of abnormal psychology places growing
emphasis on the interrelationship of the social
environment, the brain, and the rest of the body