326 : chapter 10

Mind over Matter

The opposite of conversion and somatic symp-
tom disorders—although again demonstrating
the power of psychological processes—are
instances in which people “ignore” pain or
other physical symptoms. Here a London per-
formance artist manages to smile comfortably
at onlookers while her skin is being pierced
with sharp hooks that help suspend her from

AP Photo/Lefteris Pitarakis
the ceiling above. Her action was part of a
protest to end shark finning—the practice of
cutting off a shark’s fin and throwing its still-
living body back into the sea so that the fins
can be used in the production of shark fin soup
(a food delicacy) and other goods.

at the root of hysterical disorders. These Why do the terms “hysteria”

researchers founded the Nancy School and “hysterical” currently have
in Paris for the study and treatment of such negative connotations in
mental disorders. There they were able to our society, as in “mass hysteria”
produce hysterical symptoms in normal and “hysterical personality”?
people—deafness, paralysis, blindness, and
numbness—by hypnotic suggestion, and
they could remove the symptoms by the same means (see Chapter 1). If hypnotic
suggestion could both produce and reverse physical dysfunctioning, they con-
cluded, hysterical disorders might themselves be caused by psychological processes.
Today’s leading explanations for conversion and somatic symptom disorders
come from the psychodynamic, behavioral, cognitive, and multicultural models.
None has received much research support, however, and the disorders are still
poorly understood.
The Psychodynamic View As you read in Chapter 1, Freud’s theory of
psychoanalysis began with his efforts to explain hysterical symptoms. Indeed, he
was one of the few clinicians of his day to treat patients with these symptoms
seriously, as people with genuine problems. After studying hypnosis in Paris, Freud
became interested in the work of an older physician, Josef Breuer (1842–1925).
Breuer had successfully used hypnosis to treat a woman he called Anna O., who
suffered from hysterical deafness, disorganized speech, and paralysis (Ellenberger,
1972). On the basis of this and similar cases, Freud (1894) came to believe that
hysterical disorders represented a conversion of underlying emotional conflicts into
physical symptoms and concerns.
Observing that most of his patients with hysterical disorders were women,
CC primary gain In psychodynamic
theory, the gain people derive when their Freud centered his explanation of such disorders on the needs of girls during their
somatic symptoms keep their internal con- phallic stage (ages 3 through 5). At that time in life, he believed, all girls develop a
flicts out of awareness. pattern of desires called the Electra complex: each girl experiences sexual feelings for
CCsecondary gain In psychodynamic her father and at the same time recognizes that she must compete with her mother
theory, the gain people derive when their for his affection. However, aware of her mother’s more powerful position and of
somatic symptoms elicit kindness from
others or provide an excuse to avoid cultural taboos, the child typically represses her sexual feelings and rejects these
unpleasant activities. early desires for her father.
 Disorders Featuring Somatic Symptoms : 327

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 reexperi-
ence sexual anxiety throughout her life. Whenever events trig-
ger sexual feelings, she may feel an unconscious need to hide
them from both herself and others. Freud concluded that some
women hide their sexual feelings by unconsciously converting
them into physical symptoms and concerns.
Most of today’s psychodynamic theorists take issue with
parts of Freud’s explanation of conversion and somatic symp-
tom disorders (Nickel et al., 2010), but they continue to believe
that sufferers of the disorders have unconscious conflicts carried

Hero Images/Getty Images

forth from childhood, which arouse anxiety, and that the they
convert this anxiety into “more tolerable” physical symptoms
(Brown et al., 2005).
Psychodynamic theorists propose that two mechanisms are
at work in these disorders—primary gain and secondary gain.
Electra Complex Goes Awry
People derive primary gain when their bodily symptoms keep their internal
Freud argued that a hysterical disorder may
conflicts out of awareness. During an argument, for example, a man who has result when parents overreact to their daugh-
underlying fears about expressing anger may develop a conversion paralysis of ter’s early displays of affection for her father,
the arm, thus preventing his feelings of rage from reaching consciousness. People by repeatedly punishing her, for example. The
derive secondary gain when their bodily symptoms further enable them to avoid child may go on to exhibit sexual repression
in adulthood and convert sexual feelings into
unpleasant activities or to receive sympathy from others. When, for example, a physical ailments.
conversion paralysis allows a soldier to avoid combat duty or conversion blindness
prevents the breakup of a relationship, secondary gain may be at work. Similarly, the
conversion paralysis of Brian, the man who lost his wife in the boating accident,
seemed to help him avoid many painful duties after the accident, such as attending
her funeral and returning to work.
The Behavioral View Behavioral theorists propose that the physical symp-
toms of conversion and somatic symptom disorders bring rewards to sufferers (see
Table 10-4). Perhaps the symptoms remove those with the disorders from an un-
pleasant relationship or perhaps the symptoms bring attention from other people
(Witthöft & Hiller, 2010). In response to such rewards, the sufferers learn to display
the bodily symptoms more and more prominently. Behaviorists also hold that

table: 10-4

Disorders That Have Somatic Symptoms

Symptoms
Voluntary Linked to An
Control of Psychosocial Apparent
Disorder Symptoms? Factor? Goal?
Malingering Yes Maybe Yes
Factitious disorder Yes Yes No*
Conversion disorder No Yes Maybe
Somatic symptom disorder No Yes Maybe
Illness anxiety disorder No Yes No
Psychophysiological disorder No Yes No
Physical illness No Maybe No
*Except for medical attention.
328 : chapter 10

Can Pain Be Learned?

This baby is about to be given a v­ accination.
How much pain will she feel? According to
research, it depends in large part on her
mother. Infants of first-time mothers express
significantly more pain before and during vac-
cine injections than do infants of experienced

Owen Humphreys/PA Wire/Associated Press

mothers. Apparently, through facial gestures,
body language, modeling, or other condi-
tioning processes, new mothers actually help
produce more pain in their children.

people who are familiar with an illness will more readily adopt its physical symp-
toms. In fact, studies find that many sufferers develop their bodily symptoms after
they or their close relatives or friends have had similar medical problems (Marshall
et al., 2007).
Clearly, the behavioral focus on the role of rewards is similar to the psychody-
namic notion of secondary gain. The key difference is that psychodynamic theorists
view the gains as indeed secondary—that is, as gains that come only after underly-
ing conflicts produce the disorders. Behaviorists view them as the primary cause of
the development of the disorders.
Like the psychodynamic explanation, the behavioral view of conversion and
somatic symptom disorders has received little research support. Even clinical case
reports only occasionally support this position. In many cases the pain and upset
that surround the disorders seem to outweigh any rewards the symptoms might
bring.
The Cognitive View Some cognitive theorists propose that conversion and
somatic symptom disorders are forms of communication, providing a means for
people to express emotions that would otherwise be difficult to convey (Hallquist
et al., 2010; Koh et al., 2005). Like their psychodynamic colleagues, these theorists
hold that the emotions of people with the disorders are being converted into physi-
cal symptoms. They suggest, however, that the purpose of the conversion is not to
defend against anxiety but to communicate extreme feelings—anger, fear, depres-
sion, guilt, jealousy—in a “physical language” that is familiar and comfortable for
the person with the disorder.
According to this view, people who find it particularly hard to recognize or ex-
DS M -5 CONTROVE RSY press their emotions are candidates for conversion and somatic symptom disorders.
Overreactions to Medical Illnesses? So are those who “know” the language of physical symptoms through firsthand ex-
According to DSM-5, even people perience with a genuine physical ailment. Because children are less able to express
whose physical symptoms are caused their emotions verbally, they are particularly likely to develop physical symptoms
by significant medical problems may as a form of communication (Shaw et al., 2010). Like the other explanations, this
qualify for a diagnosis of somatic cognitive view has not been widely tested or supported by research.
symptom disorder if they are overly
anxious or upset by their medical prob-
lems. Critics worry that many patients
The Multicultural View Most Western clinicians believe that it is inappro-
who are understandably upset by the priate to produce or focus excessively on somatic symptoms in response to personal
development of cancer, heart disease, distress (Shaw et al., 2010; So, 2008; Escobar, 2004). That is, in part, why conversion
or other serious diseases will incor- and somatic symptom disorders are included in DSM-5. Some theorists believe,
rectly receive a diagnosis of somatic
symptom disorder.
however, that this position reflects a Western bias—a bias that sees somatic reactions
as an inferior way of dealing with emotions (Moldavsky, 2004; Fábrega, 1990).
 Disorders Featuring Somatic Symptoms : 329

In fact, the transformation of personal distress into somatic complaints is the norm BETWEEN THE LINES
in many non-Western cultures (Draguns, 2006; Kleinman, 1987). In such cultures,
Diagnostic Confusion
the formation of such complaints is viewed as a socially and medically ­correct—and
less stigmatizing—reaction to life’s stressors. Studies have found very high rates of Many medical problems with vague or
confusing symptoms—multiple sclerosis,
stress-caused bodily symptoms in non-Western medical settings throughout the hyperparathyroidism, lupus, and chronic
world, including those in China, Japan, and Arab countries ­(Matsumoto & Juang, fatigue syndrome are examples—­
2008). People throughout Latin America seem to display the most somatic reactions frequently have been misdiagnosed as
(Escobar, 2004, 1995; Escobar et al., 1998, 1992). Even within the United States, conversion or somatic symptom disor-
der. In the past, whiplash was regularly
Hispanic Americans display more somatic reactions in the face of stress than do misdiagnosed in this way (Shaw et al.,
other populations. 2010; Ferrari, 2006; N
­ emecek, 1996).
The lesson to be learned from such multicultural findings is not that somatic
reactions to stress are superior to psychological ones or vice versa, but rather, once
again, that both bodily and psychological reactions to life events are often influ-
enced by one’s culture. Overlooking this point can lead to knee-jerk mislabels or
misdiagnoses.

How Are Conversion and Somatic Symptom

Disorders Treated?
People with conversion and somatic symptom disorders usually seek psychotherapy
only as a last resort. They believe that their problems are completely medical and
at first reject all suggestions to the contrary (Lahmann et al., 2010). When a physi-
cian tells them that their symptoms or concerns have a psychological dimension,
they often go to another physician. Eventually, however, many patients with these
disorders do consent to psychotherapy, psychotropic drug therapy, or both (Raj
et al., 2014).
Many therapists focus on the causes of these disorders (the trauma or anxiety tied
to the physical symptoms) and apply insight, exposure, and drug therapies (Boone,
2011). Psychodynamic therapists, for example, try to help those with somatic symp-
toms become conscious of and resolve their underlying fears, thus eliminating the
need to convert anxiety into physical symptoms (Nickel et al., 2010; Hawkins,
2004). Behavioral therapists use exposure treatments. They expose clients to features
of the horrific events that first triggered their physical symptoms, expecting that the
The Positive Side of Swearing
clients will become less anxious over the course of repeated exposures and more Famous English soccer player Wayne Rooney
able to face those upsetting events directly rather than through physical channels yells out in pain after being struck by a ball in
(Stuart et al., 2008). And biological therapists use antianxiety drugs or certain anti- the groin. Research indicates that swearing can
depressant drugs to help reduce the anxiety of clients with conversion and somatic help reduce pain, and not just pain on display
in conversion and somatic symptom disorders,
symptom disorders (Raj et al., 2014; Parish & Yutzy, 2011). but even pain like Rooney’s (­Stephens et al.,
Other therapists try to address the physical symptoms of these disorders rather 2009).
than the causes, using techniques such as suggestion, reinforce-
ment, or confrontation (Parish & Yutzy, 2011). Those who
employ suggestion offer emotional support to patients and tell
them persuasively (or hypnotically) that their physical symp-
toms will soon disappear (Hallquist et al., 2010; Lahmann et al.,
2010). Therapists who take a reinforcement approach arrange Martin Rickett/Press Association via AP Images
for the removal of rewards for a client’s “sickness” symptoms
and an increase of rewards for healthy behaviors (Raj et al.,
2014; North, 2005). And therapists who take a confrontational
approach try to force patients out of the sick role by straight-
forwardly telling them that their bodily symptoms are without
medical basis (Sjolie, 2002). Researchers have not fully evalu-
ated the effects of these particular approaches on conversion
and somatic symptom disorders (Martlew, Pulman, & ­Marson,
2014; Boone, 2011).
330 : chapter 10

table: 10-5 Illness Anxiety Disorder

Dx Checklist People with illness anxiety disorder, previously known as hy-
pochondriasis, are chronically anxious about their health and are
Illness Anxiety Disorder
convinced that they have or are developing a serious medical illness,
1. Person is preoccupied with thoughts about having or despite the absence of somatic symptoms (see Table 10-5). They
getting a significant illness. In reality, person has no
repeatedly check their body for signs of illness and misinterpret
or, at most, mild somatic symptoms.
various bodily events as signs of serious medical problems. Typically
2. Person has easily triggered, high anxiety about health. the events are merely normal bodily changes, such as occasional
3. Person displays unduly high number of health- coughing, sores, or sweating. Those with illness anxiety disorder
related behaviors (e.g., keeps focusing on body) or persist in such misinterpretations no matter what friends, relatives,
dysfunctional health‑avoidance behaviors (e.g., avoids and physicians say. Some such people recognize that their concerns
doctors). are excessive, but many do not.
4. Person’s concerns continue to some degree for at Although illness anxiety disorder can begin at any age, it starts
least 6 months. most often in early adulthood, among men and women in equal
numbers. Between 1 and 5 percent of all people experience the
(Information from: APA, 2013)
disorder (Abramowitz & Braddock, 2011). Their symptoms tend
to rise and fall over the years. Physicians report seeing many cases
­(Dimsdale et al., 2011). As many as 7 percent of all patients seen by primary care
physicians may display the disorder.
Theorists typically explain illness anxiety disorder much as they explain various
anxiety disorders (see Chapter 5). Behaviorists, for example, believe that the illness
fears are acquired through classical conditioning or modeling (Marshall et al., 2007).
Cognitive theorists suggest that people with the disorder are so sensitive to and
threatened by bodily cues that they come to misinterpret them (Witthöft & Hiller,
2010; ­Williams, 2004).
People with illness anxiety disorder usually receive the kinds of treatments that
are used to treat obsessive-compulsive disorder (see pages 164–169). Studies reveal,
for example, that clients with the disorder often improve considerably when given
the same antidepressant drugs that are helpful in cases of obsessive-compulsive disor-
der (Bouman, 2008). Many clients also improve when treated with the behavioral
approach of exposure and response prevention, often combined with cognitive inter-
ventions (Abramowitz & Braddock, 2011). In this approach, the therapists repeat-
edly point out bodily variations to the clients while, at the same time, preventing
them from seeking their usual medical attention. In addition, cognitive therapists
guide the clients to identify, challenge, and change their beliefs about illness that are
helping to maintain their disorder (Hedman et al., 2011).
CCillness anxiety disorder A disorder
in which people are chronically anxious
about and preoccupied with the notion
that they have or are developing a serious
Psychophysiological Disorders:
medical illness, despite the absence of Psychological Factors Affecting
somatic symptoms. Previously known as
hypochondriasis. Other Medical Conditions
CC psychophysiological disorders About 85 years ago, clinicians identified a group of physical illnesses that seemed to
Disorders in which biological, psychologi-
cal, and sociocultural factors interact to be caused or worsened by an interaction of biological, psychological, and ­sociocultural
cause or worsen a physical illness. Also factors (Dunbar, 1948; Bott, 1928). Early editions of the DSM labeled these illnesses
known as psychological factors affecting psychophysiological, or psychosomatic, disorders, but DSM-5 labels them as
other medical conditions.
psychological factors affecting other medical conditions (see Table 10-6).
CCulcer A lesion that forms in the wall of The more familiar term “psychophysiological” will be used in this chapter.
the stomach or of the duodenum. It is important to recognize that significant medical symptoms and conditions
CCasthma A medical problem marked are involved in psychophysiological disorders and that the disorders often result
by narrowing of the trachea and bron- in serious physical damage (APA, 2013). They are different from the factitious,
chi, which results in shortness of breath,
wheezing, coughing, and a choking conversion, and illness anxiety disorders that are accounted for primarily by psy-
sensation. chological factors.