253

When a bodily ailment has an excessive and disproportionate impact on the person, has no apparent medical cause, or is inconsistent with known medical diseases, physicians may suspect a conversion disorder or a somatic symptom disorder. Consider the plight of Brian:

Eventually, Brian received a diagnosis of conversion disorder (see Table 8.2). 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.

254

Conversion disorder often is hard, even for physicians, to distinguish from a genuine medical problem (Ali et al., 2015; Parish & Yutzy, 2011). 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 (de Schipper et al., 2014). 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 (Boone, 2011). 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 8.1 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 (Ali et al., 2015; Scheidt et al., 2014). 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 (Lahman et al., 2010). 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. 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 (Raj et al., 2014). It typically appears suddenly, at times of extreme stress, and lasts a matter of weeks (Kukla et al., 2010). Some research suggests that people who develop the disorder tend to be generally suggestible (see MindTech below); many are highly susceptible to hypnotic procedures, for example (Parish & Yutzy, 2011; Roelofs et al., 2002). It is thought to be a rare problem, occurring in at most 5 of every 1,000 persons.

255

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 the symptoms (APA, 2013) (see Table 8.3). 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.

256

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.

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

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 (Taycan et al., 2014; Dimsdale & Creed, 2010). The pattern typically lasts for many years, fluctuating over time but rarely disappearing completely without therapy (Parish & Yutzy, 2011; Abbey, 2005).

257

Between 0.2 and 2.0 percent of all women in the United States may experience a somatization pattern in any given year, compared with less than 0.2 percent of men (North, 2005; APA, 2000). 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.

Predominant Pain Pattern If the primary feature of somatic symptom disorder is pain, the person is said to have a predominant pain pattern. Patients with conversion disorder or another pattern of somatic symptom disorder may also experience pain, but it is the key symptom in this pattern. The source of the pain may be known or unknown. Either way, the concerns and disruption produced by the pain are disproportionate to its severity and seriousness.

Although the precise prevalence has not been determined, this pattern appears to be fairly common (Nickel et al., 2010). It 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. For example, Laura, a 36-year-old woman, reported pains that went far beyond the usual symptoms of her tubercular disease, called sarcoidosis:

For many years, conversion and somatic symptom disorders were referred to as hysterical disorders. This label was meant to convey the prevailing belief that excessive and uncontrolled emotions underlie the bodily symptoms found in these disorders.

Work by Ambroise-Auguste Liébault and Hippolyte Bernheim in the late nineteenth century helped foster the notion that such psychological factors were at the root of hysterical disorders. These researchers founded the Nancy School in Paris for the study and treatment of mental disorders. There they were able to produce hysterical symptoms in normal 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 concluded, hysterical disorders might themselves be caused by psychological processes.

258

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, Freud centered his explanation of such 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 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 symptom disorders (Nickel et al., 2010), but they continue to believe that sufferers of the disorders have unconscious conflicts carried forth from childhood, which arouse anxiety, and that 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. People derive primary gain when their bodily symptoms keep their internal conflicts out of awareness. During an argument, for example, 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 derive secondary gain when their bodily 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, such as attending her funeral and returning to work.

The Behavioral View Behavioral theorists propose that the physical symptoms of conversion and somatic symptom disorders bring rewards to sufferers (see Table 8.4). Perhaps the symptoms remove those with the disorders from an unpleasant 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 people who are familiar with an illness will more readily adopt its physical symptoms. 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).

259

Clearly, the behavioral focus on the role of rewards is similar to the psychodynamic 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 underlying 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 (Koo et al., 2014; Hallquist et al., 2010). Like their psychodynamic colleagues, these theorists hold that the emotions of people with the disorders are being converted into physical symptoms. They suggest, however, that the purpose of the conversion 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 person with the disorder.

According to this view, people who find it particularly hard to recognize or express their emotions are candidates for conversion and somatic symptom disorders. 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 particularly likely to develop physical symptoms as a form of communication (Shaw et al., 2010). Like the other explanations, this cognitive view has not been widely tested or supported by research.

The Multicultural View Most Western clinicians believe that it is inappropriate to produce or focus excessively on somatic symptoms in response to personal distress (Shaw et al., 2010; So, 2008; Escobar, 2004). That is, in part, why conversion and somatic symptom disorders are included in DSM-5. Some theorists believe, 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).

260

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, 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 stress-caused bodily symptoms in non-Western medical settings throughout the world, including those in China, Korea, Japan, and Arab countries (Zhou et al., 2015; Matsumoto & Juang, 2008). People throughout Latin America seem to display the most somatic reactions (Escobar, 2004, 1995; Escobar et al., 1998, 1992). Even within the United States, Hispanic Americans display more somatic reactions in the face of stress than do other populations.

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 influenced by one’s culture. Overlooking this point can lead to knee-jerk mislabels or misdiagnoses.

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 physician 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 (Ali et al., 2015; Boone, 2011). Psychodynamic therapists, for example, try to help those with somatic symptoms become conscious of and resolve their underlying fears, thus eliminating the need to convert anxiety into physical symptoms (Nickel et al., 2010; Hawkins, 2004). Alternatively, behavioral therapists use exposure treatments. They expose clients to features of the horrific events that first triggered their physical symptoms, expecting that the clients will become less anxious over the course of repeated exposures and more able to face those upsetting events directly rather than through physical channels (Stuart et al., 2008). And biological therapists use antianxiety drugs or certain antidepressant drugs to help reduce the anxiety of clients with conversion and somatic symptom disorders (Raj et al., 2014).

Other therapists try to address the physical symptoms of these disorders rather than the causes, using techniques such as suggestion, reinforcement, or confrontation (Ali et al., 2015; Parish & Yutzy, 2011). Those who employ suggestion offer emotional support to patients and tell them persuasively (or hypnotically) that their physical symptoms will soon disappear (Hallquist et al., 2010; Lahmann et al., 2010). Therapists who take a reinforcement approach arrange 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 straightforwardly telling them that their bodily symptoms are without medical basis (Sjolie, 2002). Researchers have not fully evaluated the effects of these particular approaches on conversion and somatic symptom disorders (Martlew, Pulman, & Marson, 2014; Boone, 2011).

261