Chapter 9: Disorders Featuring Somatic Symptoms

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- Psychological factors may contribute to somatic, or bodily, illnesses in a variety of ways. The physician who sees Jarell has some possibilities to sort out. Jarell could be faking his pain and dizziness to avoid taking some tough tests. Alternatively, he may be imagining his illness, that is, faking to himself. Or he could be overreacting to his pain and dizziness. Then again, his physical symptoms could be both real and significant, yet triggered by stress: whenever he feels extreme pressure, such as a person can feel before an important test, Jarell's gastric juices may become more active and irritate his intestines, and his blood pressure may rise and cause him to become dizzy. Finally, he may be coming down with the flu. Even this "purely medical" problem, however, could be linked to psychological factors. Perhaps weeks of constant worry about the exams and presentation have weakened Jarell's body so that he was not able to fight off the flu virus. Whatever the diagnosis, Jarell's state of mind is affecting his body. The physician's view of the role played by psychological factors will in turn affect the treatment Jarell receives.
You have observed throughout the book that psychological disorders frequently have physical causes. Dysfunctional brain circuits and abnormal neurotransmitter activity, for example, contribute to generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. Is it surprising, then, that bodily illnesses may have psychological causes? Today's clinicians recognize the wisdom of Socrates' assertion made many centuries ago: "You should not treat body without soul."
The idea that psychological factors may contribute to somatic illnesses has ancient roots, yet it had few proponents before the twentieth century. It was particularly unpopular during the Renaissance, when medicine began to be a physical science and scientists became committed to the pursuit of objective "fact." At that time, the mind was considered the territory of priests and philosophers, not of physicians and scientists. By the seventeenth century, the French philosopher René Descartes went so far as to claim that the mind, or soul, is totally separate from the body — a position called mind-body dualism. Over the course of the twentieth century, however, numerous studies convinced medical and clinical researchers that psychological factors such as stress, worry, and perhaps even unconscious needs can contribute in major ways to bodily illness.
- DSM-5 lists a number of psychological disorders in which bodily symptoms or concerns are the primary features of the disorders. These include factitious disorder, in which patients intentionally produce or feign physical symptoms; conversion disorder, which is characterized by medically unexplained physical symptoms that affect voluntary motor or sensory functioning; somatic symptom disorder, in which people become disproportionately concerned, distressed, and disrupted by bodily symptoms; illness anxiety disorder, in which people who are anxious about their health become preoccupied with the notion that they are seriously ill despite the absence of bodily symptoms; and psychological factors affecting other medical conditions, disorders in which psychological factors adversely affect a person's general medical condition
- LIKE JARELL, PEOPLE who become physically sick usually go to a physician. Sometimes, however, the physician cannot find a medical cause for the problem and may suspect that other factors are involved. Perhaps the patient is malingering — intentionally feigning illness to achieve some external gain, such as financial compensation or time off from work (Chafetz, Bauer, & Haley, 2020). Jarell, for example, would be malingering if he knowingly made up his symptoms simply to avoid taking his midterm exams.
Alternatively, a patient may intentionally produce or feign physical symptoms from a wish to be a patient; that is, the motivation for assuming the sick role may be the role itself (Irwin & Bursch, 2019). Physicians would then decide that the patient is manifesting factitious disorder (see Table 9-1). Consider, for example, the symptoms of Adia, a patient with bacteremia — presence of bacteria in the blood, which can, if not corrected, lead to the life-threatening condition called sepsis. As you will see, the medical team's handling of Adia's right to privacy raises ethical issues, but the case itself illustrates the features of factitious disorder.
- Factitious disorder is known popularly as Munchausen syndrome, a label derived from the exploits of Baron von Münchhausen, an eighteenth-century cavalry officer who journeyed from tavern to tavern in Europe telling fantastical tales about his supposed military adventures (Prabhu et al., 2020). People with factitious disorder often go to extremes to create the appearance of illness (APA, 2013). Many give themselves medications secretly. Some, like the woman just described, inject drugs to cause bleeding, infections, or other problems. Still others use laxatives to produce chronic diarrhea (Wald, 2019). High fevers are especially easy to create. In studies of patients with a prolonged mysterious fever, 9 percent were eventually diagnosed with factitious disorder
- People with factitious disorder often research their supposed ailments and are impressively knowledgeable about medicine. Many eagerly undergo painful testing or treatment, even surgery. When confronted with evidence that their symptoms are factitious, they typically deny the charges and leave the hospital; they may enter another hospital the same day.
Clinical researchers have had a hard time determining the prevalence of factitious disorder, since patients with the disorder hide the true nature of their problem (Chafetz et al., 2020). Overall, the pattern appears to be more common in women than men. Men, however, may more often have severe cases. The disorder usually begins during early adulthood.
Factitious disorder seems to be particularly common among people who (1) received extensive treatment for a medical problem as children, (2) carry a grudge against the medical profession, or (3) have worked as a nurse, laboratory technician, or medical aide (Jimenez et al., 2020; Yates & Feldman, 2017). A number have poor social support, few enduring social relationships, and little family life (Irwin & Bursch, 2019).
The precise causes of factitious disorder are not understood, although clinical reports have pointed to factors such as depression, unsupportive parental relationships during childhood, and extreme needs for attention and/or social support that are not otherwise available (Jimenez et al., 2020; Irwin & Bursch, 2019). Nor have clinicians been able to develop dependably effective treatments for this disorder.
Psychotherapists and medical practitioners often report feelings of annoyance or anger toward people with factitious disorder, feeling that these people are, at the very least, wasting their time. Yet people with the disorder feel they have no control over the problem, and they often experience great distress.
In a related pattern, factitious disorder imposed on another, known popularly as Munchausen syndrome by proxy, parents or caretakers make up or produce physical illnesses in their children, leading in some cases to repeated painful diagnostic tests, medication, and surgery (Ban & Shaw, 2019) (see Table 9-1 again). If the children are removed from their parents and placed in the care of others, their symptoms disappear
- Eventually, Brian received a diagnosis of conversion disorder, also referred to as functional neurological symptom disorder (see Table 9-2). People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases (APA, 2013). In short, they have neurological-like symptoms — for example, paralysis, blindness, or loss of feeling — that have no neurological basis.
- Conversion disorder often is hard, even for physicians, to distinguish from a genuine medical problem (Bransfield & Friedman, 2019). In fact, it is always possible that a diagnosis of conversion disorder is a mistake and that the patient's problem has an undetected neurological or other medical cause (Stone & Sharpe, 2020a, 2019). Because conversion disorders are so similar to "genuine" medical ailments, physicians sometimes rely on oddities in the patient's medical picture to help distinguish the two. The symptoms of a conversion disorder may, for example, be at odds with the way the nervous system is known to work. In a conversion symptom called glove anesthesia, numbness begins sharply at the wrist and extends evenly right to the fingertips. As Figure 9-1 shows, real neurological damage is rarely as abrupt or evenly spread out.
- The physical effects of a conversion disorder may also differ from those of the corresponding medical problem (Stone & Sharpe, 2020a). For example, when paralysis from the waist down, or paraplegia, is caused by damage to the spinal cord, a person's leg muscles may atrophy, or waste away, unless physical therapy is applied. The muscles of people whose paralysis is the result of a conversion disorder, in contrast, do not usually atrophy. Perhaps those with a conversion disorder exercise their muscles without being aware that they are doing so. Similarly, people with conversion blindness have fewer accidents than people who are organically blind, an indication that they have at least some vision even if they are unaware of it.
Unlike people with factitious disorder, those with conversion disorder do not consciously want or purposely produce their symptoms. Like Brian, they almost always believe that their problems are genuinely medical. This pattern is called "conversion" disorder because clinical theorists used to believe that individuals with the disorder are converting psychological needs or conflicts into their neurological-like symptoms (Cretton et al., 2020). Although some theorists still believe that conversion is at work in the disorder, others prefer alternative kinds of explanations, as you'll see later.
Conversion disorder usually begins between late childhood and young adulthood; it is diagnosed at least twice as often in women as in men (de Vroege et al., 2020). It often appears suddenly, at times of extreme stress (Stone & Sharpe, 2020b). In some, but far from all, cases, conversion disorder lasts a matter of weeks. Some research suggests that people who develop the disorder tend to be generally suggestible (see MindTech). Many are highly susceptible to hypnotic procedures, for example (Williamson, 2019; Tsui et al., 2017). It is thought to be a rare problem, occurring in 1 to 5 of every 500 persons
- People with somatic symptom disorder become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing, and their lives are greatly disrupted by those symptoms (APA, 2013) (see Table 9-3). The symptoms last longer but are less dramatic than those found in conversion disorder. In some cases, the somatic symptoms have no known cause; in others, the cause can be identified. Either way, the person's concerns are disproportionate to the seriousness of the bodily problems.
- Two patterns of somatic symptom disorder have received particular attention. In one, sometimes called a somatization pattern, the individual experiences a large and varied number of bodily symptoms. In the other, called a predominant pain pattern, the person's primary bodily problem is the experience of pain.
1. Person experiences at least one upsetting or repeatedly disruptive physical (somatic) symptom.
2. Person experiences an unreasonable number of thoughts, feelings, and behavior regarding the nature or implications of the physical symptoms, including one of the following: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.
3. Physical symptoms usually continue to some degree for more than 6 months.
- Like Sheila, people with a somatization pattern of somatic symptom disorder experience many long-lasting physical ailments — ailments that typically have little or no physical basis. This pattern, first described by Pierre Briquet in 1859, is also known as Briquet's syndrome. A sufferer's ailments often include pain symptoms (such as headaches or chest pain), gastrointestinal symptoms (such as nausea or diarrhea), sexual symptoms (such as erectile or menstrual difficulties), and neurological-type symptoms (such as double vision or paralysis).
People with a somatization pattern usually go from doctor to doctor in search of relief. They often describe their many symptoms in dramatic and exaggerated terms. Most also feel anxious and depressed (Cao et al., 2020; Levenson, 2020a). The pattern typically lasts for many years, fluctuating over time but rarely disappearing completely without therapy.
- Around 4 percent of all people in the United States may experience a somatization pattern in any given year, women much more commonly than men (Levenson, 2020a). The pattern often runs in families; as many as 20 percent of the close female relatives of women with the pattern also develop it. It usually begins between adolescence and young adulthood.