Disorders Featuring Somatic Symptoms

Transcription

1 10-1 CHAPTER:10 Disorders Featuring Somatic Symptoms CHAPTER SUMMARY In previous chapters, you read how stress and anxiety can negatively affect functioning and lead to disorders such as generalized anxiety disorder and posttraumatic stress disorder. Stress and anxiety can contribute to several other kinds of disorders, such as those characterized by somatic symptoms and the various psychophysical disorders (e.g., ulcers, insomnia, hypertension, and headaches). These disorders are the subject of this chapter. TOPIC OVERVIEW Factitious Disorder Conversion Disorder and Somatic Symptom Disorder Conversion Disorder Somatic Symptom Disorder What Causes Conversion and Somatic Symptom Disorders? How Are Conversion and Somatic Symptom Disorders Treated? Illness Anxiety Disorder Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions Traditional Psychophysiological Disorders New Psychophysiological Disorders Psychological Treatments for Physical Disorders Putting It Together: Expanding the Boundaries of Abnormal Psychology

2 10-2 LECTURE OUTLINE I. DISORDERS FEATURING SOMATIC SYMPTOMS A. Psychological factors may contribute to somatic, or bodily, illnesses in a variety of ways B. This idea has ancient roots, yet it had few proponents before the twentieth century 1. It was particularly unpopular during the Renaissance, when the mind was considered the territory of priests and philosophers, not of physicians and scientists 2. By the seventeenth century, French philosopher René Descartes claimed that the mind, or soul, is totally separate from the body a position called mind-body dualism 3. Over the twentieth century, however, numerous studies convinced medical and clinical researchers that psychological factors such as stress, worry, and even unconscious needs can contribute in major ways to bodily illness C. DSM-5 lists a number of psychological disorders in which bodily symptoms or concerns are primary features, including: 1. Factitious disorder 2. Conversion disorder 3. Somatic symptom disorder 4. Illness anxiety disorder 5. Psychological factors affecting other medical conditions II. FACTITIOUS DISORDER A. Sometimes when physicians cannot find a medical cause for a patient s symptoms, he or she may suspect other factors are involved 1. Patients may malinger, intentionally fake illness to achieve external gain (e.g., financial compensation, military deferment) 2. Patients may be manifesting a factitious disorder intentionally producing or faking symptoms simply out of a wish to be a patient (See Table 10-1, text p. 318.) B. Known popularly as Munchausen syndrome, people with factitious disorder often go to extremes to create the appearance of illness 1. Many secretly give themselves medications to produce symptoms 2. Patients often research their supposed ailments and are impressively knowledgeable about medicine C. Clinical researchers have a hard time determining the prevalence of this disorder as patients hide the true nature of their problems 1. Overall, the pattern appears to be more common in women than men, and the disorder usually begins during early adulthood 2. Factitious disorder seems to be particularly common among people who received extensive medical treatment as children, carry a grudge against the medical profession, or have worked as a nurse, lab technician, or medical aide D. 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 that is not otherwise available E. Psychotherapists and medical practitioners often become annoyed or angry at people with a factitious disorder, feeling that those people are wasting their time 1. People with the disorder, however, feel they have no control over their problems and often experience great distress

3 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 III. CONVERSION DISORDER A. People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases (See Table 10-2, text p. 321.) 1. In short, individuals experience neurological-like symptoms blindness, paralysis, or loss of feeling that have no neurological basis B. Conversion disorder often is hard to distinguish from genuine medical problems 1. It is always possible that a diagnosis of conversion disorder is a mistake and the patient s problem has an undetected medical cause 2. Physicians sometimes rely on oddities in the patient s medical picture to help distinguish the two a. For example, conversion symptoms may be at odds with the known functioning of the nervous system, as in cases of glove anesthesia (See Figure 10-1, text p. 322.) C. Unlike people with factitious disorder, those with conversion disorder don t consciously want or produce their symptoms D. This pattern is called conversion disorder because clinical theorists used to believe that individuals with the disorder were converting psychological needs into neurological symptoms E. Conversion disorder usually begins between late childhood and young adulthood 1. It is diagnosed in women twice as often as in men 2. It typically appears suddenly, at times of stress 3. It is thought to be rare, occurring in at most 5 of every 1,000 persons IV. SOMATIC SYMPTOM DISORDER A. People with somatic symptom disorder become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing B. Two patterns of somatic symptom disorder have received particular attention: 1. Somatization pattern a. People with a somatization pattern experience many long-lasting physical ailments that have little or no organic basis b. This disorder is also known as Briquet s syndrome c. A sufferer s ailments often include pain symptoms, gastrointestinal symptoms, sexual symptoms, and neurological symptoms d. Patients usually go from doctor to doctor in search of relief e. Patients with this pattern often describe their symptoms in dramatic and exaggerated terms and most also feel anxious and depressed f. The pattern typically lasts for many years; symptoms may fluctuate over time but rarely disappear completely without therapy g. Between 0.2 percent and 2 percent of all women in the United States experience a somatization pattern in any given year (compared with less than 0.2 percent of men) h. The pattern often runs in families and begins between adolescence and young adulthood: as 20 percent of the close female relatives of women with the pattern also develop it 2. Predominant pain pattern a. If the primary feature of somatic symptom disorder is pain, the individual is said to have a predominant pain pattern b. Although the precise prevalence has not been determined, this pattern appears to be fairly common

4 10-4 c. The pattern often develops after an accident or illness that has caused genuine pain d. The pattern may begin at any age, and more women than men seem to experience it V. WHAT CAUSES CONVERSION AND SOMATIC SYMPTOM DISORDERS? A. For many years, conversion and somatic symptom disorders were referred to as hysterical disorders 1. This label was to convey the prevailing belief that excessive and uncontrolled emotions underlie the bodily symptoms B. Today s leading explanations come from the psychodynamic, behavioral, cognitive, and multicultural models 1. None has received much research support, and the disorders are still poorly understood C. The psychodynamic view 1. Freud believed that hysterical disorders represented a conversion of underlying emotional conflicts into physical symptoms 2. Because most of his patients were women, Freud centered his explanation on the needs of girls during their phallic stage (ages 3 5) a. According to Freud, during this stage, girls develop a pattern of sexual desires for their fathers (the Electra complex) while recognizing that they must compete with their mothers for their fathers attention b. Because of the mother s more powerful position, however, girls repress these sexual feelings c. Freud believed that if parents overreacted to such feelings, the Electra complex would remain unresolved and the child would reexperience sexual anxiety through her life d. Freud concluded that some women unconsciously hide their sexual feelings in adulthood by converting them into physical symptoms 3. Today s psychodynamic theorists take issue with parts of Freud s explanation a. They do continue to believe that sufferers of these disorders have unconscious conflicts carried from childhood 4. Psychodynamic theorists propose that two mechanisms are at work in these disorders: a. Primary gain Bodily symptoms keep internal conflicts out of conscious awareness b. Secondary gain Bodily symptoms further enable people to avoid unpleasant activities or to receive sympathy from others D. The behavioral view 1. Behavioral theorists propose that the physical symptoms of hysterical disorders bring rewards to sufferers a. May remove individual from an unpleasant relationship b. May bring attention from other people 2. In response to such rewards, sufferers learn to display symptoms more and more prominently 3. This focus on rewards is similar to the psychodynamic idea of secondary gain, but behaviorists view them as the primary cause of the development of the disorder 4. Like the psychodynamic explanation, the behavioral view of these disorders has received little research support E. The cognitive view 1. Some cognitive theorists propose that conversion and somatic symptom disorders are forms of communication, providing a means for people to express difficult emotions

5 10-5 a. Like psychodynamic theorists, cognitive theorists hold that emotions are being converted into physical symptoms b. This conversion is not to defend against anxiety but to communicate extreme feelings c. Like the other explanations, this cognitive view has not been widely tested or supported by research F. The multicultural view 1. Some theorists believe that Western clinicians hold a bias that considers somatic symptoms as an inferior way of dealing with emotions a. The transformation of personal distress into somatic complaints is the norm in many non-western cultures b. 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 VI. HOW ARE CONVERSION AND SOMATIC SYMPTOM DISORDERS TREATED? A. People with conversion and somatic symptom disorders usually seek psychotherapy only as a last resort B. Many therapists focus on the causes of the disorders and apply techniques including: 1. Insight, to help those with somatic symptoms become conscious of and resolve their underlying fears 2. Exposure, to 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 3. Drug Therapy antianxiety or antidepressant medication to help reduce the anxiety C. Other therapists try to address the physical symptoms of these disorders, applying techniques such as: 1. Suggestion offering emotional support that may include hypnosis 2. Reinforcement a behavioral attempt to change reward structures 3. Confrontation an overt attempt to force patients out of the sick role D. Researchers have not fully evaluated the effects of these particular approaches on these disorders VII. ILLNESS ANXIETY DISORDER [Video: Hypochondriasis Becomes Illness Anxiety Disorder] A. 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 (See Table 10-5, text p. 330.) B. They repeatedly check their bodies for signs of illness and misinterpret bodily symptoms as signs of a serious illness 1. Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or sweating C. Although some patients recognize that their concerns are excessive, many do not D. Although this disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers E. Between 1 percent and 5 percent of all people experience the disorder F. For most patients, symptoms rise and fall over the years G. Theorists explain this disorder much as they explain various anxiety disorders: 1. Behaviorists: illness fears are acquired through classical conditioning or modeling 2. Cognitive theorists: people with the disorder are so sensitive to and threatened by bodily cues that they come to misinterpret them

6 10-6 H. Individuals with illness anxiety disorder typically receive the kinds of treatments applied to OCD: 1. Antidepressant medication 2. Exposure and response prevention (ERP) 3. Cognitive interventions VIII. PSYCHOPHYSIOLOGICAL DISORDERS: PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITONS [Video: Hypnosis: Medical and Psychological Applications; Stress and the Immune System: Caretakers at Risk] A. 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 B. Early versions of the DSM labeled these illnesses psychophysiological, or psychosomatic, disorders 1. DSM-5 labels them as psychological factors affecting medical condition (See Table 10-6, text p. 331.) 2. It is important to recognize that these psychophysiological disorders bring about actual physical damage C. Traditional psychophysiological disorders 1. 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 2. Recent research has shown that many other physical illnesses may be caused by an interaction of psychosocial and physical factors 3. The traditional psychophysiological disorders include: a. Ulcers lesions in the wall of the stomach resulting in burning sensations or pain, vomiting, and stomach bleeding (a) Experienced by more than 25 million people at some point in their lives (b) Causal psychosocial factors: environmental pressures, intense feelings of anger or anxiety (c) Causal physiological factors: bacterial infection b. Asthma a narrowing of the body s airways that makes breathing difficult (a) Affects up to 25 million people in the United States each year (b) Most victims are children or younger teenagers at the time of first attack (c) Causal psychosocial factors: environmental pressures or anxiety (d) Causal physiological factors: allergies, a slow-acting sympathetic nervous system, weakened respiratory system c. Insomnia difficulty falling asleep or maintaining sleep (a) 10 percent of the population has insomnia that lasts months or years (b) Causal psychosocial factors: high levels of anxiety or depression (c) Causal physiological factors: overactive arousal system, certain medical ailments d. Chronic headaches frequent intense aches of the head or neck that are not caused by another physical disorder (a) Tension headaches affect 45 million Americans a year (b) Migraine headaches affect 23 million Americans a year (c) Causal psychosocial factors: environmental pressures, general feelings of helplessness, anger, anxiety, depression (d) Causal physiological factors: abnormal serotonin activity, vascular problems, muscle weakness e. Hypertension chronic high blood pressure, usually producing few outward symptoms (a) Affects 75 million Americans each year

7 (b) Causal psychosocial factors: constant stress, environmental danger, general feelings of anger or depression (c) Causal physiological factors: obesity, smoking, poor kidney function, high proportion of collagen in an individual s blood vessels (i) 10 percent caused by physiological factors alone f. Coronary heart disease caused by a blocking of the coronary arteries; the term refers to several problems, including myocardial infarction (heart attack) (a) Nearly 18 million people in the United States suffer from some form of coronary heart disease (i) It is the leading cause of death among Americans (both men and women) (b) Causal psychosocial factors: job stress, high levels of anger or depression (c) Causal physiological factors: high level of cholesterol, obesity, hypertension, the effects of smoking, lack of exercise 4. A number of factors contribute to the development of psychophysiological disorders, including: a. Biological factors (a) Defects in the autonomic nervous system (ANS) are believed to contribute to the development of psychophysiological disorders (b) Other more specific biological problems also may contribute (i) For example, a weak gastrointestinal system may create a predisposition to developing ulcers b. Psychological factors (a) According to many theorists, certain needs, attitudes, emotions, or coping styles may cause people to overreact repeatedly to stressors, thereby increasing their likelihood of developing a psychophysiological disorder (b) Examples include a repressive coping style and the Type A personality style particularly hostility and time urgency c. Sociocultural factors (a) Adverse social conditions may set the stage for psychophysiological disorders (i) One of society s most adverse social conditions is poverty (ii) Research also reveals that belonging to ethnic and cultural minority groups increases the risk of developing these disorders and other health problems 5. Clearly, biological, psychological, and sociocultural variables combine to produce psychophysiological disorders a. In fact, the interaction of psychosocial and physical factors is now considered the rule of bodily function, not the exception b. In recent years, more and more illnesses have been added to the list of psychophysiological disorders and researchers have found many links between psychosocial stress and a range of physical illnesses D. New psychophysiological disorders 1. Are physical illnesses related to stress? a. The development of the Social Readjustment Rating Scale in 1967 enabled researchers to examine the relationship between life stress and the onset of illness (See Table 10-8, text p. 338.) b. Using this measure, studies have linked stresses of various kinds to a wide range of physical conditions c. Overall, the greater the amount of life stress, the greater the likelihood of illness (a) Researchers have even found a relationship between traumatic stress and death 10-7

8 d. One shortcoming of the Social Readjustment Rating Scale is that it does not take into consideration the particular stress reactions of 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 2. Researchers have increasingly looked to the body s immune system as the key to the relationship between stress and infection a. This area of study is called 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 b. Among the most important cells in this system are the lymphocytes, white blood cells that circulate through the lymph system and bloodstream and attack invaders c. Lymphocytes include helper T-cells, natural killer T-cells, and B-cells d. 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 e. 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 (a) Biochemical activity (i) Stress leads to increased activity of the sympathetic nervous system, including a release of norepinephrine (ii) In addition to supporting nervous system activity, this chemical also appears to slow down the functioning of the immune system (iii) Similarly, the body s endocrine glands reduce immune system functioning during periods of prolonged stress through the release of corticosteroids (iv) In addition, corticosteroids also trigger increased cytokines, which lead to chronic inflammation (b) Behavioral changes (i) Stress may set into 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 (c) Personality style (i) An individual s personality style, including his or her level of optimism, constructive coping strategies, and resilience, can help him or her to experience better immune system functioning and to be better prepared to fight off illness (d) Social support (i) 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 (ii) Studies have shown that social support and affiliation with others may actually protect people from stress, poor immune system functioning, and subsequent illness, or help speed up recovery from illness or surgery E. Psychological treatments for physical disorders 1. The most common of these interventions are relaxation training, biofeedback, meditation, hypnosis, cognitive interventions, support groups, and therapies designed to increase awareness and expression of emotion 2. The field of treatment that combines psychological and physical interventions to treat or prevent medical problems is known as behavioral medicine a. Relaxation training 10-8

9 (a) People can be trained to relax their muscles at will, a process that sometimes reduces feelings of anxiety (b) Relaxation training can help prevent or treat medical illnesses that are related to stress (c) Relaxation training often is used in conjunction with medication in the treatment of high blood pressure (d) Relaxation training often is used alone to treat headaches, insomnia, asthma, pain after surgery, certain vascular diseases, and the undesirable effects of cancer treatments b. Biofeedback (a) Patients given biofeedback training are connected to machinery that gives them continuous readings about their involuntary bodily activities (b) 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 (c) Some biofeedback training has been effective in the treatment of heartbeat irregularities, asthma, migraine headaches, high blood pressure, stuttering, and pain c. Meditation (a) Although meditation has been practiced since ancient times, Western health care professionals have only recently become aware of its effectiveness in relieving physical distress (b) The technique involves turning one s concentration inward and achieving a slightly changed state of consciousness (c) Meditation has been used to manage pain, treat high blood pressure, heart problems, insomnia, and asthma d. Hypnosis (a) Individuals who undergo hypnosis are guided into a sleeplike, suggestible state during which they can be directed to act in unusual ways, to feel unusual sensations, or to forget remembered events (b) With training, hypnosis can be done without a hypnotist (self-hypnosis) (c) This technique seems to be particularly helpful in the control of pain and is now used to treat such problems as skin diseases, asthma, insomnia, high blood pressure, warts, and other forms of infection e. Cognitive interventions (a) People with physical ailments have sometimes been taught new attitudes or cognitive responses as part of treatment (b) One example is stress inoculation training, in which patients are taught to rid themselves of negative self-statements and to replace them with coping self-statements f. Support groups and emotion expression (a) 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 (b) These techniques have been used to treat a variety of illnesses, including HIV, asthma, cancer, and arthritis g. Combination approaches (a) Studies have found that the various psychological interventions for physical problems tend to be equal in effectiveness (b) Psychological treatments often are most effective when they are combined with other psychological and medical treatments (c) With these combined approaches, today s practitioners are moving away from their counterparts of centuries past 10-9

10 LEARNING OBJECTIVES Describe the criteria for diagnosing factitious disorder and explain how it differs from malingering Define conversion disorder and somatic symptom disorder and discuss the primary theories of causality and the major treatment approaches Explain how physicians distinguish between conversion disorders and true medical problems Describe illness anxiety disorder, its diagnosis, theories of causality, and primary treatment approaches Compare and contrast the psychodynamic, cognitive, and behavioral views of conversion and somatic symptom disorders. Discuss the multicultural view and the possible role of biology Describe the traditional psychophysiological disorders: ulcers, asthma, chronic headaches, hypertension, and coronary heart disease Discuss how perceptions of control, personality, mood, and social support affect immune system functioning Discuss typical psychological treatments for psychophysiological disorders. KEY TERMS antigen asthma behavioral medicine conversion disorder coronary heart disease factitious disorder hypertension hypochondriasis illness anxiety disorder immune system insomnia lymphocytes migraine headache muscle contraction (tension) headache primary gain psychoneuroimmunology psychophysiological disorders secondary gain somatic symptom disorder Type A personality style Type B personality style ulcer

11 10-11 Internet Sites MEDIA RESOURCES Please see Appendix A for full and comprehensive references. Sites relevant to Chapter 10 material are: This site includes characteristics, etiology, symptoms, and treatment of somatoform disorders. A comprehensive page from the Centers for Disease Control that discusses the many factors associated with chronic fatigue syndrome. Mainstream Films Films relevant to Chapter 10 material are listed and summarized below. Key to Film Listings: P = psychopathology focus T = treatment focus E = ethical issues raised Please note that some of the films suggested may have graphic sexual or violent content due to the nature of certain subject matters. Hannah and Her Sisters From 1986, this film chronicles the changing relationships among three sisters living in New York City. The film stars Woody Allen as a television writer who is divorced from Hannah and suffers from hypochondriasis. P, T, comedy The Piano This Oscar-winning film from 1993 stars Holly Hunter as Ada, a mute-by-choice nineteenth-century woman sent to New Zealand in an arranged marriage with a patriarchal landowner (Sam Neill). P, serious film Send Me No Flowers From 1964, this film stars Rock Hudson as a sweet and hopeless man with hypochondriasis. P, comedy The Sixth Sense While not a major point of this 1999 film about a young boy who sees dead people, a child victim of Munchausen syndrome by proxy is briefly profiled. P, commercial/suspense/paranormal film Vanilla Sky This 2001 Cameron Crowe film stars Tom Cruise as a successful publisher who finds his life taking a turn for the surreal after a car accident. P, commercial/suspense film Other Films: Hollywood Ending (2002), somatoform disorder (hysterical blindness). P, comedy/commercial film Play It Again Sam (1972), hypochondriacs. P, comedy film Tommy (1975), somatoform disorder. P, T, rock musical Films on Demand is a Web-based digital delivery service that has impressive psychology holdings. Their catalog can be accessed here:

12 CLASS DEMONSTRATIONS AND ACTIVITIES Case Study Present a case study to the class. Panel Discussion Have students volunteer (or assign them) to portray mental health workers from different theoretical perspectives in a panel discussion. Each student should present the main explanation and treatment for the disorders focusing on somatic symptoms disorders from his or her theoretical background. Students in the audience can ask questions of the panelists. In addition, other students can role-play patients suffering from particular somatoform disorders. (NOTE: A brief reminder about sensitivity and professionalism is worthwhile here.) Have the panelists or audience members attempt to make a diagnosis. Guest Speaker Invite a medical doctor or practitioner who specializes in treatment of psychophysiological stress disorders. He or she can speak to the prevalence and impact as well as the biological, psychological, social causes, and interventions for such disorders. Diathesis-Stress Model Direct genetic causation of illness and abnormal behavior is rare. Recent research has indicated that many illnesses are now understood in terms of the interaction of hereditary and environmental factors, the diathesis-stress model. According to this theory, certain genes or hereditary vulnerability give rise to a diathesis or a constitutional predisposition. When an individual s predisposition is then combined with certain kinds of environmental stress, illness may result. With diseases like heart disease, high blood pressure, and cancer, both hereditary and environmental factors play a role. A major effort in abnormal research and clinical practice is to identify specific risk factors in a given individual, including both family history and personal lifestyle, and then predict the onset of a mental disorder. (1) Here s $25,000 to be awarded to... Children sometimes display Type A personality styles. Researchers suggest that children as young as age 3 can exhibit a marked pattern of impatience and restlessness, expectation of meeting high standards, and above--average competitiveness. Children may carry these personality styles, with their potential impact on health, with them into adulthood. Ask groups to develop a school-based program for encouraging these children to develop healthier personality patterns or styles. Have the groups present their ideas, and then have the class vote on which group receives the grant to implement its idea. (2) Here s $25,000 to be awarded to... Divide students into groups, and then ask each group to propose a method to reduce the occurrence of one of the causes of heart disease, such as smoking, drinking, and being overweight. Have the groups present their ideas, and then have a class vote to see which group receives the grant to implement its idea.

13 10-13 (1) The Anonymous Five-Minute Essay: Type A Personality Ask for anonymous descriptions of known individuals who fit the description of the Type A personality. Likely examples will be Little League coaches, teachers, parents, and even some friends. Inform students that you may select their example for reading to the class. (2) The Anonymous Five-Minute Essay: I can t go to school today. An amusing exercise is to have students write down their most creative excuse for not attending school (related to faking illness). It should be an episode in which they probably could have qualified for some acting award, and of which, to this day, they are proud. Inform students that you may select their example for reading to the class. Distinguishing Disorders The differences among factitious disorder, conversion disorder, somatic symptom disorder, and illness anxiety disorder can be difficult to understand. Pointing out the important distinction (such as the voluntary nature of symptoms in factitious disorder) is very helpful. Displaying the DSM criteria for these disorders simultaneously while leading a discussion of the differences also can be helpful. SUGGESTED TOPICS FOR DISCUSSION Psychology and Medical Health The major causes of morbidity (illness) and mortality (death) have changed in the last century. In the early 1900s, viruses and bacteria were the leading causes of death. Ask students what happened to change this. (Medical and scientific advances, such as antibiotics, vaccinations, and improvements in sanitation helped stamp out these causes of death.) Presently, leading causes of death include heart disease (related to smoking, eating, not exercising, being overweight, drinking too much), cancer, motor vehicle accidents, and suicide. Ask students what these causes have in common (all are related to behavior). Psychology is thus becoming increasingly important in overall health care. In particular, the field of health psychology is emerging as an important area of the health care system. Munchausen Syndrome versus Munchausen Syndrome by Proxy Lead a discussion of these disorders. Munchausen syndrome is an extreme and long-term form of factitious disorder in which a person feigns symptoms to gain admission to a hospital and receive treatment. Munchausen syndrome by proxy is a factitious disorder in which parents feign or produce physical illnesses in their children. In both instances, the motivation appears to be attention from doctors (either because one is sick or because one s child is sick). See PsychWatch on p. 320 of the text for more information. (1) Open Discussion: Student Health Conduct a class discussion on the relationship between health and academic stress. Ask students whether health problems fit a semester pattern. Discuss students beliefs about their own roles in health and sickness. Can they affect the course of a disease? Can they do things that prevent diseases? Is the patient to blame for being ill?

14 10-14 (2) Open Discussion: Too Healthy? Ask students whether there should be a DSM category for people who are overly concerned with good health. They can be people who are overly concerned about eating habits or exercise. Should these types of behaviors be considered abnormal? ASSIGNMENTS/EXTRA CREDIT SUGGESTIONS (1) Write a Pamphlet With the use of a software program like Microsoft Publisher or simply paper and markers, students can create a pamphlet on the stress or psychophysiological disorders. Encourage students to be as accurate and up-to-date as possible and to present all sides of the disorder (e.g., alternate treatment approaches or theories). (2) Write a Pamphlet With the use of a software program like Microsoft Publisher or simply paper and markers, students can create a pamphlet on one or all of the somatoform disorders. Students also could create a pamphlet on How to Detect Malingering or A Guide to Factitious Disorders. Encourage students to be as accurate and up-to-date as possible and to present all sides of the disorder (e.g., alternate treatment approaches or theories). Keep a Journal In addition to helping students synthesize material, this activity is helpful in developing writing skills. Have students keep a journal of their thoughts on course material throughout the semester. This can be done in the first or last five minutes of class or as an out-of-class assignment. Have students submit their journals for review on an ongoing basis because they can have a tendency to delay writing until the end of the semester. Some suggestions for journal topics include reactions to the case examples; strengths and weaknesses of prevailing theoretical explanations; hypothetical conversations with sufferers of specific disorders, and so on. Essay Topics For homework or extra credit, have students write an essay addressing one (or more) of the following topics: (1) PsychWatch on p. 320 in the text discusses Munchausen syndrome by proxy, a disorder many find both bizarre and disturbing. What do you think is the explanation behind such a disorder? Do you think Munchausen syndrome by proxy should be considered a psychological disorder or a crime? (2) Compare and contrast factitious disorder, malingering, and somatic symptom disorders. What are your reactions to each type of disorder? Do you think they are legitimate psychological disorders? Research Topics For homework or extra credit, have students write a research report addressing one (or more) of the following topics: (1) Conduct a Psych Info search and write an annotated bibliography on treatments for factitious disorder and somatic symptom disorders. What theoretical model is being evaluated? (2) Using the text on p. 330 as a starting point, discuss the change from the label hypochondriasis to illness anxiety disorder. Was this change motivated by scientific reasons or social reasons?

15 10-15 Film Review To earn extra credit, have students watch one (or more) of the mainstream films listed earlier in this chapter and write a brief report (3 to 5 pages). Students should summarize the plot of the film in sufficient detail to demonstrate familiarity, but they should focus their papers on the depiction of psychological abnormality. What errors or liberties did the filmmaker take? What is the message (implicit or explicit) concerning people with mental illness?