CM AP t t R I S<,,n,1tofi,rttt ,md Drut>ci,uiw Dis,tttltr•

ave you ever had the experience, particularly durin

g a time of serious stress
you felt Uke you were walking around In a daze
or like you Just wererrt au• t~n
or have you known people who constantly complain ed about being sure lhty ~re?
a serious Illness even though several medical
tests their doctor had perfo ad
railed to show anything wrong? Both of these
are examples of mild dlssot1a~
and somatoform symptoms experienced at leas
t occasionally by many Peop t
However, when these symptoms become frequ
ent and severe and lead to Sig ~.
cant distress or Impairment, a somatoform or
dissociative disorder may be d~ifi.
nosed. Somotoform and dissociative disorders appe
ar to involve more complex~•·
puuling patterns of symptoms than those we
have so far encountered. As ares d
they conrront the field of psychopathology with
some of Its most fascinating~~
difficult challenges. although unfortunately we
do not know much about them-in
part because many of them are quite rare.
The somatoform disorders are a group of cond
itions that Involve physlcat
symptoms and complaints suggesting the presence
of a medical condition but with-
out any evidence of physical pathology to acco
unt for them (APA, 2000). Despite
the range of clinical manifestations-from blind
ness or paralysis to hypochondria.
cal complaints about stomach pains thought to
be a sign of cancer-ln each case
the person Is preoccupied with some aspect of
her or his health or appearance to
the extent that she or he shows significant Impa
irments in functioning. These lndl•
viduals therefore frequently show up In the prac
tices of primary-care physicians,
who then have the difficult task of deciding how
to manage their complaints, which
have no known physical basis.
The dissociative disorders, on the other hand, are
a group of conditions involv•
Ing disruptions in a person's normally integrated
functions of consciousness, mem•
ory. Identity, or perception (APA, 2000 ). Inclu
ded here are some of the more
dramatic phenomena In the entire domain of psyc
hopathology: people who cannot
recall who they are or where they may have come
from, and people who have two
or more distinct Identities or personality states
that alternately take control of tht
individual's behavior. The term dissociation refer
s to the human mind's capacity to
engage In complex mental activity in channels
split off from, or Independent o~
•
conscious awareness.
As we have seen (Chapter 6), both somatoform
and dissociative disorders were
once included with the anxiety disorders under
the general rubric neuroses, whert
anxiety was thought to be the underlying cause
of all neuroses whether or not the
anxiety was experienced overtly. But In 1980, when
DSM-Ill abandoned attempts to
link disorders together on the basis of hypothes
ized underlying causes and Instead
focused on grouping disorders together on the
basis of overt symptomatology.~
somatoform and dissociative disorders became
separate categories from the anxt- 1
ety disorders.

1
SOMATOFORM pain. Such individuals art typically preoccupied with
~
DISORDERS state of health and with various presumed disordtn~
ems of bodily organs. Equally kty to these disordcn ~
cht
fact that the afftctcd patients hare no control _ova
•body," and somatoform disorders .involve
l•••dr& 11
In which indiviJuals complain of bodily symp-
ds that
symptoms. They are also not intentionally faking sytnr
toms or attrmpting to deaivc othtn. For 1M pJO II"'
suggest the prestnct of mNkal prob- they genuinely and 10metimts p,ssio~atdy rf\'9"
........ but for which no orpnic basis can be foun
d that som~ing is terribly wrong with their bod ies .~·
rily expuins tht symptoms ,uch as paralysis or lmct of somatoform disorders appean to vary
 Somatoform Di,or4'rrl
~dift't ring cultures (e.g., Isaac et aL, 1995; Janca
jJt 19'5)· ill r. lcsa
we w 1ocus on five more or
,_,. OfJI clisCussion.
_10 JOlll&lOform patterns t!1at .have been identified:
DSM_-lV-TR
~ (2) somatwtion disorder, (3) pain
(l) (~) conversion disorder, and (5) body dysmor- Criteria for Hypochondrlasls
~~
,.,,. A. Preoccupation with fears or contractfn1, or the idea that
one has. a serious disease, based on misinterpretation of
HYPO"'ondriasls bodily symptoms.

~ to DSM-IV·TR, people with hypochondriaais B. Preoccupation persists despite appropriate medical

evaluation and reassurance.
preoccupied either with fears of contracting a serious
If! or with the idea that they actually have such a dis- C. Preoccupation causes cUnically sl_gnlficant distress or
Impairment.
~ though they do not. Their preoccupations arc all
~ 00 1 ,nisinterp~etation ?f one or mo~e bodily signs D. Duration of at least 6 months.
symptoms (e.g., being convinced that their slight cough Source: Adapted with p~rmlsslon from the Dlapostic and
~ irion of lung cancer). Of.bed course the decision that a
··
Statistical Manual of Mental Disorders. Fourth Edition. T~ Revision
,a ..,,- driacal comp1· amt 1s as on a m1s1nterpreta- (Copyright 2000). Am~riam Psychiatric AssodatJon.
bypOCbon
tion of bodily signs or symptoms can be made only after a
moroughmedical evaluation does not find a medical con ..
ditioD that could account for the signs or symptoms. ily functions (e.g., heart beats or bowel movements) or
Another defining criterion for hypochondriasis is that the with minor physical abnormalities (e.~ a small sore or
person is not reassured by the results of a medical evalua- an occasional cough) or with vague and ambiguous phys-
tion; that is, the fear or idea of having a disease persists ical sensations (such as a "tired heart" ~r •aching veins.,.;
despite medical reassurance. Indeed, these individuals arc APA, 2000). They attribute th~ symptoms to a sus-
sometimes disappointed when no physical problem is pected disease, and often have intrusive thoughts about
found. Finally, the condition must persist for at least 6 it. The diagnoses they mm for themselves range from
months for the diagnosis to be made, so as to not diagnose tuberculosis to cancer. exotic infections, AIDS, and
rdativdytransient health concerns. • numerous other diseases.
Not surprisingly, people with hypochondriasis usually Although people with hypochondriasis are usually in
first go to a medical doctor with their physical complaints. good physical condition, they arc sincere in their convic-
Because they are never reassured fer long. and are inclined tion that the symptoms they detect represent real illness.
to suspect that their doctor has missed something, they They are not malingering--<onsciously faking symptoms
sometimes shop for additional doctors, hoping one might to achieve specific goals such as winning a personal injury
discover what their problem really is. Because they repeat- lawsuit. Not surprisingly, given their tendency to doubt
edly reek medical advice (e.g., Fink et al., 2004), it is not the soundness of their doctor's conclusions (i.e., that they
'1lrprising that their yearly medical costs are much higher have no medical problem) and r~ommendations, the
than tboee of most of the rest of the population (e.g.. doctor-patient relationships are often marked by conflict
Hilla; Kmymann. et al., 2004; Salkovskis & Bass, 1997). and hostility.
Thae.individua1s generally resist the idea that their prob-. The following case captures a typical clinical picture
a•
Ian ~logi cal one that might best be treated by a in hypochondriasis and incidentally demonstrates that a
high level of medical sophistication does not necessarily
~ or psychiatrist.
-Jvdaondriaais may be the most commonly ~en rule out a person's developing this disorder.
....,. . disorder, with a prevalence in general medical
~ l ' atimakCI at between 2 an_d 7 percent
~ k oc:cun about equally often m men and
CID atart at almost any age, although early case An ..Abdominal Mass"
• tbe most common age of o~set. Once STltD)-
rd
llllllil• deYclops. it tends to be a chronic diso er
nd
altbougb the severity may wax a wane
MI.IClladlwith hypochondriasis often also suf-
disordm, panic disorder, ~nd/0 ! ~
0th

)fi1uider1 (especially somatiution disorder,

2004).
Individuals with bypochon-
111\MJS and highly preoccupied with bod-
 CHAPTER 8 Somatoform a,ad [)is.sociativt Disordt-.rs

~c-'"•--~, . . ...,.. • •..oi .,.

; actolllPlflWinl anser and shallle with tears In his eyes. ~ j

also desc,ibes his recent return from a to-day stav a~ :;
famou.s out-of•s.tate medical diaInost~ center to whach 1
he had been referred by an exasperated 1astroenterolo- -~
11st colleague who had reportedly •reached t~e end of .:
the Une• with his radloloIist patienL The extensive phys- j
ical and laboratory examinations performed at the center
had revealed no significant physical disease,. a con~lu- J
s1on the patient reports with resentment and d1sappo1nt·
ment rather than reliet }
The patient~ history reveals a long-standing p~ttern 1
of overconcem about personal health matters, begmning
at age 13 and exacerbated by hfs medical schoo! experi-
ence. Until fairly recently, however, he had mamtained ,
• reasonable control over these concerns, in part b~cause
he was embarrassed to reveal them to other physicians.
He is conscientious and successful in his profession and
active in community life. His wife. like his son, has
become increasingly impatient with his morbid ~reoccu-
pation about life-threatening but undetectable d1sea~es.
In describing his current symptoms. the patient
refers to n;s becoming increasingly aware, over the past
several months, of various sounds and sensations ema-
nating from his abdomen and of his sometimes being able
to feel a •firm mass" in its left lower quadrant His tenta-
tive diagnosis is carcinoma (cancer) of the colon. He tests
his stool for blood weekly and palpates his abdomen for
15 to 20 minutes every 2 to 3 days. He has performed sev-
eral X-ray studies of himself in secrecy after hours at his
office. (Adapted from Spitzer et al., 2002, pp. 88-90.) I

Hypochondriocol individuals ore preoccupied with health matre1: '

Soun:~ Adapted with permission from the DSM-IV-TR Casebook and unrealistic fears ofdiseast. They are convjnced that theyh'1'1
(Copyri&ht 2000). American Psychiatric Publishing. Inc. symptoms ofphysical il/ntss, but their complaints typically do not
t ' conform to any coh~rent symptom pattern, and they usually l'lu►!t
trouble giving a precise description of their symptoms. J
THEORETICAL PERSPECTIVES ON CAUSAL FACTORS I
0

Knowledge of causal factors in somatoform disorders, 2001 ). These d)·sfunctional assumptions might ind udf)
including hypochondriasis, is quite minimal compared to notions 6Uch as, ''Bodily changes are usually a sign of se,
many other Axis I disorders such as the mood and anxiety ous disease, because every symptom has to have an 1'dent
disorders discussed in the previous few chapters. Today fiable physical caust" or "If you don't go to the doctor
many people think hypochondriasis is closely related to soon as you notice anything unusual, thtn it will ht 1
the anxiety disorders. Indeed, many researchers today pre- late" (SaJkovskis & Bass, 1997, p. 318). . . diV1dll
fer the term health anxiety to hypochondriasis (e.g., Taylor Because of these dysfunctional assumpttons, 10
&Asmundson, 2004). Today, cognitive-behavioral views of als with hypochondriasis Sttm to focus excessive ' 3 ttcntlO
.
hypochondriasis are p~rhaps most widely accepted and
on symptoms, with recent experimental tvidence st?Wlfi
have as a cmtral tenet that it is a disorder of cognition and that these individuals do in fact have an attentional ias
~raption. Misinterpretati9ns of bodily sensations are
illness-related information (Owffls, Asmundsond ~g
currently a defining feature of the syndrome, but in the
cognitive-behavioral view, these misinterpretations also 2004). They also perceive their symptoms as m~rt 3 to
ous than they really are. and Judge a part~cular d~~ h-1 •
play a causal role. It is bclinted that an individual's past
experiencn with illnessn (in both themselves and othcn,
more likcly or dangm,u, than it really as. Ona t er
6
misinterpreted a symptom, they tend to look (or ,~n S
and as observed in the mass media) Jead to the devdop-
mmt of a set of dysfunctional wumptions about l)'lllp- Ing evidence and to diacount evidmu that they.are ~tab
toms and diseases that may predispose a pmon to health: In fact. they 1ee1n to baine that ~IJ'l~1uer,
dnreloping hypochondmais (Bouman. Eifert. & lejucz. means bang completely -,mptom-fm .(Ri~ilitf (
·1999; Salkovskis & Bas5y 1997, Salkonkia & Warwick. Margraf, 1991a). 1bq uo perceiw their p rndY
~ able to cupe 1111h the mne. ..otrt
 5"fflllto/'1ml DisDrdm

_. a a-, I99~) and see themselves 8 weak and

(s,a ,,;tolerate ph)'Slcal tffo'"!- ~r exrrci se ( Rief et al., SomatizatJon Disorder
~ this tinds to create a v1c1o us cycle in which their Som a~tio n disorder is charactcriud by many diff'ereot
J-:M. i,out illness and symptoms result s in physi ologic al co~p l~ts of physical ailments, over at least ~a l )Gd
,....._;..., of anxid}', which then provide furthe r fuel for ~nru ng before age 30, that are not adequately explained
~ s that they are ill by independent findings of physical illness or injury and
that lead to medical treatment or to significant life impair-
did'Jf-considtt the secondary reinforcements that indi-
-'lf itb bypOChondriasis obtain, we can better under• ment Not surprisingly, therdore, somatization disordtt is
_.d hoW !uch _patterns of_ thought a~d _behavior are see~ mo~ often among pat.ients in primary medical cart
1997;
often ~tti~g s m cuJtures all over the world (Guerje d al.,
~ 10 spite of the misery these individuals , patien ts with soma tizatio n dis-
en that when we are leu..1 ct al.. 200 I). Jndeed
~ Most of us learn as childr to health care system s becau se
provi ded and, fur- order arc enormously costly
sick. special comforts and attention are le unnec essary hospital.iz.ations and
they often have multip
tbeffDO«, that we may be excused from a number of
surgeries (Hiller, Fichter, & Rief, 2003).
~ti es. Barsky and colleagues (1994) found that
In addition to the requirement of multiple physical
_. hyp«hondriacal patients reported much childhood
complaints, DSM-IV-TR (APA, 2000) lists four other
,kbeSS and ~in g of school. They also tend to have an symptom criteria that must be met at some time durin
g
~ amount of illness in their families while
growing osis of somat iz.a-
the course of the disord er before a diagn
up, which may lead to strong mem ories of being sick or in
perha ps also of havin g tion disorder can be made. A diagnostician need not be
pain (Pauli & Alptrs, 2002) , and a
its that sick peopl e convinud that th~ claimed illnesses actually existed in
ol,seMd some of the secondary benef patient's background histor y; the mere repor ting of them
sometiJnesttap (Cote ct al., 1996; Kelln er, 1985) .
is sufficient. The four other criteria that must be met are:
Jntercstingly, one study retested hypochondriacal
patients again 4 to 5 years later and found that those who I. Four pain symptoms. The patient must repor
ta
bad mnitttd at follow-up had acquired significantly more history of pain experienced with respect to at least
(Jal) major medical problems than their nonremitting four different sites or functions-for example, head,
countaparts (Barsky et al., 1998). In other words, it appea
rs abdomen, back, joints, or rectum, or during sexual
rhat hypochondriacal tendencies were reduced by the intercourse or urination.
occunma of serious medical conditions. The authors sug- 2. Two gastrointestinal symptoms. The patient must
gestfd that having a serious medical illness "served to legit~ report a history of at least two symptoms, other than
imae the patients• complaints, sanction their assumption pain, pertaining to the gastrointestinal systrm-such
«the sick role, and lessen the skepticism with, "'Now which they
as nausea, bloating, diarrhea, or vomiting when not
had prmously been regard ed. ... .A5 one noted that
pregnant
l know Dr.Xis paying attent ion to me, I can believ e him if
(p. 3. One saual symptom. The patient must report at
besa,snothing serious is wron g'" 744).
least one ttproductive system symptom other than
a hal£ pain-for example, sexual indifference or dysfunction,
TIUJMENT OF HYPOCHONDRIASIS At )cast menstrual irregularity. or vomiting throughout
cbaa studies on cognitive-behavioral treatment of pregnancy.
hppochondriasis have found that it can be a very effective nt
4. One pseudoneurological symptom. The patie
tratmeDt for hypochondriasis (c.~ Barsky & Ahem, must report a histor y of at )east one symptom, not
200t;I.ooper & Kinnayer, 2002; Wattar et al., 2005).
The
limited to pain, suggestive of a neurological •
~tta >mp oncn ts of this treatment approach focus on condition-for example, various symptoms that
~ • tbe patient's beliefs about illness and modifying mimic sensory or motor impairments such as loss
• I l!t;aetations of bodily sensations. The behavioral of sensation or involuntary muscle contraction in
include having patients induce innocuous
a band.
br intentionally focusing on parts of their body
CID learn that selective perception of bodily If the symptoms of somatization disorder smn similar
plap a major role. in their symptoms. Some- to you in some ways to those of hypochondriasis, that
is
also directed to engage in response preven- because there art indeed significant similarities bdwm i the
chec!dng their body as they usually do and by two conditions (and they sometimes co-occur; Mai,
2004),
• constant seeking of reassurance. The treat• but there are also enough distinguishing featum that they
• relatively brief (6-16 sessions), produced are considered two separatr disorders in DSM-JV-TR. Fw
hn,ochondriacal symptoms and beliefs, as example, although both disordm are cbaractermd by pre-
of anxiety and depression. There is also occupation with phpical s,mp toa. onl)' people with
- .. mdence that certain antidepressant hypochondriasis tend to be a>DYinced that they haft an
ellllecialllv SSRis) may be effective in treating organic disel1e. Monowr. with lrypocbondriasi the
• well (e.g.. Fallon, 2004).
•
I
frfqufntly for abdominll pain. ~ bet,. .
DSM-IV-TR ' on one c,cmion as hMnC 1 -spastic <Oton.,• ~
i-

to M.D. phySidaM, * his consulted chir o~

osteopaths for backaches, pah\s in her ~· .,c
Criteria for Somatlzatlon Disorder
1 feelin1 ofanesthesia in her fingertips. She was~ ~
admitted to a hospital following complaints of ~
A. History of many p.h)'S.icaf complaints starting before age. JO
that ottur ~ ~rat ~ars and result in treatment bttng
~ nat and chest pain and of vomitine, durinc WWadt~ ,
sought. or signmcant impairme-nt in functioning. sion she JKeived a hyster edo~ Followins tt\f ~~
she haS been troubled by spells ofa.rwerv. fainti!lg_ ~
8. Each of the fo\\owing criteria must have bff.n met at some
tting. food intolerance, and weakness and fatil\.le. rt~
tcmt during the d1sturbance: ical examinations reveal completely ntcatiw ~11\. •
{l) Four pain symptoms in different sites. (Adapted from Spitzer et al, 2002, pp. 40.H.} ~b. J
(2) Two gastroint~tinal symptoms other than pain.
Sourr:t: hapted with permission from the OSM,,v.11 ~ }
t
(3) One sexual symptom.
y (Copyright 2000). American Psychiatric PubUshini. ~ ·l
(4) One pseudoneurological symptom.
-• • ~- •~ .. I
~
C. Either (l) or (2):
:- .... ",I -"'- --

{1) After appropriate investigation, each of the symptoms

•l
under Criterion B cannot be fully explained by a
medical condition.
DEMOGRAPHICS, COMORBIDITY. AHD COURSE
ILLNESS Somatization disorder (formrrly ~
~l'f
(2) When there is a related general me-dical condition, the Briquefs syndrome after the French physician "'ho fi.1t'
physical complaints are in excess of what would M described it) has not been ~s cxtensi\'ely r~ed as sev~t
expected. eral other somatoform disorders. It usually begins in ido-i
D. Symptoms not intentionally produced or feigned. lescen~ and is believed by many to be about three to tt!J~
Source: Adapttd with ~:-mission from tht Diagnostic and times more common among women than among mai. 1l
Statistical Manual of Mental DlSOfders. Fourth Edition, Text Revlsion also tends to occur more in lower soci0tt0nomic ~l
(Copyright 2ooo). American Psychiatric Association. The lifetime prt\-ulencc has been estimated to be~ ;
0.2 and 2.0 percent in women and less than Ol f'(tctntin~
men (APA, 2000). Somatization disorder very commonh-~
co-occurs with several other disorders including ma~!
person usually has only one or a few primary symptoms, depression, panic disorder, phobic disorders, and genmJ-,:•
but in somatization disorder, by definition, there are multi- ized anxiety disorder. Although it has generally bttn cmr
ple symptoms. sidercd to be a rel.itively chronic condition \\ith a poor__
The main features of somatization disorder art illus•
tratcd in the following case summary, which also involves a
prognosis, some recent studi~ ha\'e begun to chJ.llen~t
this view with some evidence that a significant numba~i
i
secondary diagnosis of depression..
patients remit spontaneously (e.g., Crttd & Barsky, 2004 l t

CAUSAL FACTORS IN SOMATIZATION DISORDEI

case Not-Yet-Discovered Illness
De.spite its significant prevalence in medical settings, ~'t
remain quite uncertain about the dtvclopmental coul'!t
STUDY and specific etiology of somatization disorder. There is ~i-.
dence that it runs in fan1ilies and that there is a familw
This 38-year•old married woman, the mother of rave chit· linkage betwttn antisocial personality disorder in ,ntn
dren, reports to a mental health clinic with the chief com• •'J (sec Chapter .1 l) and somatization disorder in wom~
plaint of depression, meeting diagnostic criteria for -' That is, one possibility is that some common, underl}~
major depresslve disorder.... Her marriage has been a : predisposition, probably with an at least partly gc~ •
chronically unhappy one; her husband is described as an :~ basis, leads to antisocial behavior in m~n and to somatiZJ· .
alcoholic with an unstable work history, and there have ·; tion disorder in women (Cale & Lilienfeld, 2002; ~
been frequent arguments revoMng around finances, her
~exual Indifference, and her complalnts of pain durlna • 1
i et al., 1986; Lilienfeld, 1992). Mott0vtr, somatic symp~ .
•ntercourse.
and antisocial symptoms in women tend to co-occur ~ar
i & Lilimfeld, 2002). However, we do not yet ba'1t ~ (h,t
Th! history rtveats that the patient •..describes 1
understanding of this relationship. One possibilifY is . of
herself as nervous. since childhood and u havln1 been ,
continuously sickly ~&lnnln1 In he1' youth. She ~ ~
the two disorders may be linbd through a com~n u-ait ~
• ences chest pain and reportedly has been told br -data .
impulsivity, but the nature of this rdationship 15 001 } •
tors that she has a..nervous heart." She see s~ ~ understood. . . to
In addition to a poaible gendic predispOSluon rf •
• dndoping IOfflatmtion disorder, othtt contributO
 ~bly include an interaction of rtrsonal-
~~ _. learning variabltS: Pco~le high on neu-
ilft~ come from certain kinds of family
~ 11111 de,,tlop at~ency to misinterpret their
~ as thrutenmg or tvcn disabling. This
~ espiciallY liktly in famili·cs· where a child is fre-
,,,._ ~~to model~ c~mpla1nmg of ~ain and vicar-
~ - - - that co~pla1nmg about physical symptoms
~ to the garnering of ~pathy and attention (social
c,J t) and even to avoidance of responsibilities (a
~ (ezzi_ct al., ~001). This may be especially
~·ill rather disorganized and uncohcsive families
~ ~ t parental care-mo re often from lower
~ • classes-
~1,ecome clear that people with somatization
, saectivdy attend to bodily sensations and tend to
~ sensations as somatic symptoms. Like patients
:m bypOCbondriasis, they tend to catastrophize about When one physician can lnte9rate a potltnt"s core by providing
regular office 11/slts but minimum treatment. the physical
ouDOf bodily complaints and to think of themselves as functioning ofpatients with somati1ation disorder may improw.
pbysicdY weak and unable to tolerate stress or physical
,:tiYiry (Rief et al, 1998a). One possible scenario sug-
,sted by Rief et al. ( 1998a) is that a vicious cycle may sometimes an improvement in physical functioning
dtvdop. Ifone thinks of oneself as being wea~ has low tol- (although not in psychological distress; Rost, Kashner, &
erance for pain and stress, and selectively attends to bodily Smith, 1994; Smith, Monson, & Ray, 1986). This ty~ of
medical ma~gemcnt can be even more ~ffective when
semanons (while assuming that being healthy equals being combined with cognitive-behavioral therapy that focuses
without bodily sensations), one will avoid many daily
on promoting appropriate behavior such as better coping
activities that require much exertion, including physical
and personal adjustment, and discouraging inappropriate
activity. Ironically, however, lowered physical activity can
behavior such as illness behavior and preoccupation with
lead to being physially unfit. which can in turn increase physical symptoms (e.g., Mai, 2004). As with hypochon•
bodilysensations about which to catastrophize. Moreover, driasis, the focus is on changing the way the patient thinks
selectiffly attending to bodily sensations may actually about bodily sensations and reducing any ~condary gain
umase the \Jltensity of the sensations, further exacerbat- the patients may receive from physicians and family ltlffll-
ing the vicious cycle. Finally, Rief, Shaw, and Fichter bers. There are also some promising but still preliminary
(1998b) also found that patients with somatization disor- results that antidepressants <an sometimes be useful in
der bad elevated levels of cortisol (a stress hormone) and treating somatization disorder.
c6d not show normal habituation to psychological stres-
lOrs. Thus the physiological arousal caused by psychologi- ~
cal strason remains elevated and may further contribute Pain Disorder
to the bodily sensations that individuals suffering from The symptoms of pain disorder resemble the pain symp-
tbilmadition worry about. toms seen in somatiution disorder, but with pain disordu,
the other kinds of symptoms of somatiz.ation disorder are
TIEAT■ENT OF SOMATIZATION DISORDER not present. Thus pain disorder is characterized by the
Sonwizadon disorder has long been considered to be experience of persistent and seVtte pain in one or more
m Id; difficult to treat, but some recent treatment areas of the body. Although a medical condition may con-
._.Illsbegun to suggest that a certain type of medical tribute to the pain, psychological factors must be judged to
...'WIMDt and cognitive-behavioral treatments may be play an important role. In approaching the phenomenon of
One moderately effective treatment involves pain disorder, it is very important to remember that the
••111: physician who will integrate the patient's pain that is experienced is very real and can hurt as much as
the patient at regular visits (i.e., trying to pain with purely m~ical causes. It_is~ impo~t to no~e
tpparance of new problems) and by pro- that pain is always, m part, a subjective expencnce that lS
aams focused on new complaints (i.e., private and cannot be objectMly identified by others.
his symptoms as valid). At the same time, DSM-IV-TR specifics two coded subtypes: (1) pain
..,.IICU·mavoids unnecessary diagnostic test- disorder associated with psychological factors, and (2) pain
~llbllll use of medications or other thera- disorder associated with both psydlological factors and a
mlDIY'!, 2002; Mai, 2004). Several studi~ general medical condition. The first subtype applia where
:petients show substantial decreases an psychological f'acton are judged to play a major role in
~lihlla ovu subse qu~_ and the onset or maintenance of the pain-tha t is, whtre any
 CHAPTER 8

DS!\·f-I\T-T_R
Criteria for Pain Disorder
A. Pain in one or more sites as primary focus of dinical
P~tatfon.
L Pain causes slgnlfkanr distress or Impairment In
runctionlng.
C. Psychoh)gical factors Judged to have an Important role In
the pain.
D. Symptom or deficit is not lntentlonaUy produced or feigned.
Sourc•: Adapt«J with ~rmisslon from tM Diagnostic and
St~sUcai Manual of Mental Disorders. Fourth Edition, Text Revision
(Copyright 2ooo). ~rican Psychiatric As5oclation.

coexisting general medical condition is considered to be of

minimal causal significance in the pain complaint. The sec•
ond subtype applies where the experienced pain is cons.id-
~red to result from both psychological factors and some
medical condition that could ca~ pain. In either case, tlie
pain disorder may be acute (duration ofless than 6 months)
or dironic (duration of over 6 months). The experience ofpain Is always subjedivt and privatt. making j
The prevaltnce of pain disorder in the general popula- pain impossible to assess with pinpoint accura(¥ Pain dots not ;·
always v.lst in perfect co"~lation with observoblt tissut damc,r
tion is unknown. It is de.finitely quite common among
or Irritation.
patients at pain clinics. It is diagnosed more frequently in
women than in men and is very frequently comorbid with
anxiety and/or mood disorders, which may occur first or real, scheduling of d.iily activities, cogniti\·e restructurut
may arise Later as a consequence of the pain disorder (APA, and reinforce1nent of•no•pain• behaviors (Simon, 2002J
2000). People with pain disorder are often unable to work Patients receiving such treatments tend to show substan~
(they sometimes go on disability) or to perform some reductions in disability and distress although changtS i
other usuaJ daily activities. Their resulting inactivity the int~nsity of their pain tend to be smaller in m.agnitu
(induding an avoidance of physical activity) and social ' In addition, antidepressant medications (especially the,.
isolation may lead to depression and to a loss of physical cyclic antideprcSSJ.nts) have been shown to reduct P~
strength and endurance. This fatigue and Joss of strength intensity in a manner independent of the effects them
can then exacerbate the pain in a kind of vicious cycle ications may have on mood (Sin1on, 2002).
(Bouman, Eifert, & Ltjuez, 1999; Flor, Birbaumcr, & Turk,
1990). In addition, the behavioral component of pain is
quite malleable in the ~nse that it can increase when it Conversion Disorder
is reinforced by attention, sympathy, or avoidance of .Conversion disorder involves a pattern in which S)'IIl
unwanted activities (Bouman et al., l 999). Such individu-- toms or deficits affecting sensory or voluntary mot~:
als may also rtpeatcdly seek out new doctors in the hope of tions lead one to think a patient has a med1 .
getting medical confirmation of their pain or to obtain neurological condition. However, upon mcdi~ aam.
~cations to reJin1e their suffering. • tion, it becomts apparent that the pattern of syinpto:"
111
deficits cannot be fully explained by any known h~·
TREATMENT Of SOMATOFORM PAIN DISORDER
Ptrbaps because jt is a less complex and multifaceted dis-
condition. A kw typical examples include partia! ~ant
blindness, deafness, and pseudoscizures. In addition,
r~
ordtt than somatizatioo disorder, pain disorder is usually chological &cton must be judged to play an irnPorur:' 0
also a.sier to treat. Jndted, cognitive-behavioral tech- in the symptoms or dmcits, because the symptom~ 0~
niques have been widely used in the ·treatment of both 0
eitbet start or are aacabated by preceding tm; ~ot
physiaJ and "psychogenic• pain syndromes. Tratmmt mterpfflonai mnllicll or .uasors. finally, t ~10
programs using these t~niques generally indude reJu. mUlt DGt be l:demioo-Dy producing or faking tbt -.
ation training, support and validation that the pain is t.omt. •wll fwc1Ja1ted 1a1t.r- (APA. 2000).
 Somatoform Dtwrda-s

f.ufY obscn'"Jr~ns d.uing bad to Freud suggtsted

--..1 very
v"rsion disorder sho~"'lt'U
.1...t O)S I J'NF~
•
•·1thdcoo
,
~xr«tcd •
1ittk of ~ an1td}' an ka.r that would bet. Th is ~: ;
UJl"I"" • D S M -I V -T R
of sigh
- ~ --ith • rara lyz td arm or loss
iffi~n,e--Frencb
&.:l ol ~ . (~~ as 14 ~-lie inJ way the patient Criteria for Conversion Disorder
'-" 6the ~~ tndifteren,c ) in the
for a long time to be A. On@ or more symptoms affectin
g voluntary motor or
~ whzt ~ wron~ w~ ~ou ght rological or other
for conversion disorder. sensory function that suggest neua
,a ialtpOIUl't di.tgnostic enten on
}loa tlff , mo tt careful ~
later showed that la belle medical conditio n.
about 30 to 50 ~rc ent associated with the
~ ~"tllally occurs m only 8. Psychological factors Judged to be
ede d by conflicts or
sion disorder, so it has 1..ucc symptoms because they were prec
_-
ol p.abffits with. con ,-er n
. r.
a mt mo n arom rece nt editions of DS~f. In other stressors.
~ a
explained by a general
pr.,"f. it is now thought tha t most
patients with conversion C. Svmptom or deficit cannot be fully
concerned about medical condition.
disorder are actually qui te anxious and ess or impairment in
tfliir s,-mptoms (Iezzi et al., 200 I). D. Symptom or deficit causes distr
most intriguing and functioning.
~- asi on ~r de r is one of the
y, and we still have tht Diapostic and
tvfflmg ~tt ttn. s m ps}-dlopatholog Source: Adopt«/ with pam/sslon from
ly, contcn1porary s. fourth EditJon. Teet Revision
modi to learn abo ut it. Unfortunate Statfstkal Manual of Mental Disorder
ic Assoc:iotlon.
n very sparse. The term (Copyright :1000). Ammcan Psychiatr
meardi on this disord~r has bee
and historically this
a1tn'tffion disorder is relath-ely recent,
were grouped
disorder was o~ of several disorders that being somati-
others
rogctha' und a the tm n hysteria (the
cal per son alit y; see Chapter 2).
utio n dis ord a and hysteri pe may not be feasible
tuia for these dis- unpleasant situation, but literal esca
Freud used the term conversion /1ys or socially acceptable. ~1or~ver.,
although becoming sick
in his practice), because
ordm {which were fairly com mo n or disabled is more socially acce ptab le, this is true only if
e an expression of
M ~ that t~ symptoms wer the person's motivation to do so
is unconscious.
unc onscious conflict
ttpres.scd satW me rgy -th at is, the was Thus, in contemporary terms, the prim idance of
ary gain for
her sexual desires
that a person feh abo ut his or conversion symptoms is continued
esca pe or avo
, the anxiety threatens unconscious ( that is,
repres.scd. However, in Freud's view a stressful situation. Because this is all
to b«.ome conscious, so it is unc
onsciously con,•ertcd into the symptoms and the
g the person to avoid the person secs no relation between
a bodily disturbance, thereby allowin go away onJy if the
example, a person's stressful situation), the symptoms
having to deal with the ronflicL For resolved. Relatedly,
masturbate might be stressful situation has been removed or
guilty fttling.s abo ut the desire to the term secondary pin , which
originally rd'erfflf to
han d This is not done bestow beyond the •pr i-
50lftd by dn-cloping a paralyzed advantages that the symptom(s)
is not aware of the ic conflict, has also
consciously, of course, and the person mary gain" of neutralizing intrapsych
origin or meaning of the physica
l sym pto ~ Freud also to refer to any •me ma 1•
btt n retained. GeneralJy, it is used
iety and intrapsychic loved ones or finan-
thought that the reduction in anx circumstance. such as attention from
ntained the condi- reinforce the main-
conflict was the primary gain tha t mai cial compensation, that would tend to
n had many sources of
tion, but he noted that patients ofte tcnanct of disability.
iving sympathy and
secondary gain as we l such as rece HIC
attmtioo from loved ones. DECREASING PREVALENCE AND DEMOGRAP
ion disorders were onc e
CHARACT£RlmCS Convers
, £SCAPE, AND SEC· (especia lly) military life.
PRECIPITATING CIRCUMSTANCES relatively common in civilian and
ud's theory that conver- rder was the mo st fre-
ONDARY GAINS Although Fre In World War I, co~ rsi on diso
version of satW me am on g~
sion symptonu are caused by the con quently diagnosed psychiatric syndro
blems into physical ing World War II. Con -
confticts or oth er psychological pro it was also relatively common dur
side psychodynamic occurred ·under highly stra sfu l
symptoms is no Jon gtt accepted out version disorder typically
ical observations abo ut who would ordinar-
cird a, many of Freud's astute clin combat conditions and involved men
incorporated into sion S)' lllp tolm -
ily be considered stable. Ha e, conver
still
primary and s«a nda ry gain ar~
contanporary views of conversion ~r
de r. Although _the
sucb as paralysis of tM ~
, soldier to avoid an
condition is still called a convm
ion dasorder, th~ physical
anxiety-arousing com bat situatio
n without bang labeled 1
the rather ~u s
symptoms are usually seen as serving coward or being subject to murt-mani
al.
function of providing a plausible l~~ excuse, enabling_ an
Today, ~ . coma:li ou cliaord m comtiture ont,,
~Jy stre ss~ ••tu• ned for mmtal
indmdual to aca pt' or avoid an into some I to J purmt oE aD dilOlda, nfe
ibility for ~ •· 1M pe nt popula-
Ilion without having to take respons ~~ treatmmL Tbe ~ ill
~rs on ~ ~ • hwfac• flCi-JMld haft hem
TJpicaDy, it is thought that the deslJ'e to escape the tio n• unknown. but ela l dw
traafflltic nff lt that motivates th~
I
 CHAPTER 8 • • ,,..... Di1,1rdtrs
S.,matoform awI[)US(Ki,i ... ~

dge the psychological component of ,L ..

acknoWle . h 111
holding to the belief that t e symptoms were '-'it Gt~,
parasites. . ~
Conversion disorder occurs two to ten tirn~ -~
often in women than in men. It can develop at any a;o-
most commonly occurs between. ~arly adolescenet l,_
early adulthood (Maldonado. & ifi Spiegel, 2001 }. It gt"n--~
has a rapid onset afte~ a s1gn can~ stressor and-•aq~ ;:..,
resolves within 2 weeks 1f the stressor 1s removed, altho0ftti
it commonly recurs. In ?"any other cases, how(Ver, it h~
more chronic course. Like most other somatoforrn ~•
ders conversion disorder frequently occurs along .• •
other, disorders, esp~c•·a11Yma!or
• d ~p~ess•~n
• , anxiety dhot.
"'
ders, and somatiza uon and d1ssoc1attve disorders.
.
RANGE Of CONVERSION DIS~RD£_R SYMPT0'5
The range of symptom s f?r convers10~ disorder is Plictt.
cally as diverse as for physically based ailments. In d ~
ing the clinical picture in con~ersion disorder, it is useful to
. think in terms of four categories of ~ptoms : (I) ~sorj.
.' • ~ (2) motor, (3) seizures, and (4) mixed pr~ntatio n fro
the first three categories (APA, 2000). 11
., _.. l i1
~~-~-- -
.--...... M-:;,:_
-.- _ . ....,_
~ vf
~~ ~., # .• ,._~;,._,~':? A
'°\· ... .& '?,."".''!" .
i
✓.
: - ~ : ; ; .._ ~~J'~:; .41~~-. ·._:,. . ;:...,..c;~e, p, ~-"1
~ -~- ~ Sensory Symptoms or Defldts Conversion disor~
• .. -.::..1.~ > ...-,
~----:~.a . . . ....
.-~,,-
______ ,___ ,!...-~-•..- -~. ....-=.~ ~
can involve almost any sensory modality, and it can oftci
Conversion disord~rs we~ fairly common during World War I and
be diagnosed as a conversion disorder because sympto
World War II. The disorder typically occurred in otherwise •normal• 111
men during st~ssful combat conditions. The symptoms of in the affected area are inconsistent with how knowt
conversion disorder (e.g., paralysis of the legs) enabled a soldier anatomical sensory pathways operate. Today the senso~
to avoid high-anxiety combat situations without being labeled a symptoms or deficits are most often in the visual S)'Stella
coward or being court-martialed. (especially blindness and tunnel vision), in the audito~
system (especially deafness), or in the sensitivity to fetlini
(especially the anaesthesias). In the anaesthesias, the pa~
around 0.005 percent (APA, 2000). Interestingly enough, son loses her or his sense of feeling in a part of the bodj
the decreasing prevalence of conversion disorder seems to One of the most common is gltwt anaesthesia, in which~
be closely related to our growing sophistication about penon cannot fttl anything on the hand in the area wh~
medical and psychological disorders: A conversion disor• gloves are wom, although the loss of sensation usu.llf
der apparently loses its defensive (unction if it can be maka no anatomical sense.
readily shown to lack an organic basis. When it does occur i.
With conversion blindness, the person reports that~
today, it is most likely to occur in rural people from lower
or she cannot see and yet can often navigate about a rooai
socioeconomic circles who are medically unsophisticated.
without bumping into furniture or other objects. \\'i~
For example, a highly unusual recent "outbreak" of cases
conversion deafness, the person reports not being ab!c tQ
of severe conversion disorder involving serious motor
hear and yet orients appropriately upon "hearinf his~
weakness and wasting symptoms were reported in five 9-
her own name. Such observations lead to obvious ques•
to 13-year-old girls Jiving in a poor rural Amish commu•
tions: In conversion blindness (and deafness), can affected
nity (all within a 21-month period and all within a close
distance of one another). Each of these girls had experi-
persons actually not see or hear, or is the sensory •mfiorma..:.
enced substantial psychosocial stressors including behav-
tion received but sattned from consciousness? In ~ener~
ioral problems and dysfunctional family dynamics. There the mdence supports the idea that the sensory inpu~ .
had also been a serious crisis in the local church, leading registered but that it is somehow screened from tXP!,
to a great deal of community stress (see Cassady, Kirschke. conscioua recognition. This implicit perception will ht ~
et al, 2005 ). Fortunately, after the carrgivers of these girls ruaecllattr.in Developments in Thinking 8.2 on page 2 '
were educated regarding the psychological nature of the
symptoms and given advice to stick with one doctor, min- . . . _ . , . tt1■1 • • n rea' •
Dlfldta Motor conversio
imize stress, and avoid reinforcement of th~ •sick role: tiona a1toGWer a,ride ~ of symptoms (e.g., ~tald~~-
four of the five girls showtd significant improvement over ado &· $plll,J.-1!;1or aample . conversion paraJys~
the next 3 months. In the fifth case the family refused to -,,;,l_l r,..._ -~ ibp 1imb such as an arm ~r ~n~ .
•~-•~ lt-U, sel«t ivefo rcma in
. 1
j
·1
 ~~;"~~- .
..,.._,.... ,-•~~--

l I
. S... C~- ,pe zsah mfll!C S.•,N 't';f~
(r.-, ,s.,.. 20P !lel. ~~,. ~1"l e..
~-

Sri • • QJm1mioo ~~~~

... be ol ~ ~ ~~ ~
.c:aaes. •.1.,:....L-_-L~--~
~ a-cx:wD' IIC' ....;--.p-:.a .. srizun:s in some WJ,"S
td aa wua:,Y k fairly w--til dmmt ,.tintd ,ia moddn lllPOI U.ffT ISSUE S •• IHAG.ltOSU(G co11w u;o111
..,5cal ~ {Bowm m & !.fubo d, ZfLJ5). .for- DtSORDU Btam. etht s, nt;m i : i ~ ~
allt¥ ', p;ititm.s 1ritb ~ c s do oor ~ :ur, a n ~ a~ r L~ l ~ a m . . . ~ ~
Eili b-A mvities ana do not show confusion md 1os1 °' OOHS a n ~ ~ d:iff.ro!t. ft i5 au.cw tha a renon
"'i'..h ~ ~ S)i::! ;-~ ~ ~ ~
dS1!1 ~ u patim ts '5i!h ~ ~ ~
mewfo! md ~ cn!trirurian. lLfut1 ,~1~·. bow-
~~~ rzti c'nt s,.; th~ sczuraoom iOOW'
~ . ~ a n sti2 oa:cc Ncta ~2S ma~a l
~ thmh i.~ about md writhing oot Stt11 with bur
tauh a¥r bec omc ~~c ht~ clnm -
~ md thq- rardy in_iutt-tbcmsch-ts in &!Ii or lose
cfYgJ>(lVS ha dtdion:J ~ from in ~ ~
11&..b
adlol ma- their bawds or bbdda:, u patifflu ~Ji trur
estim.:es ol m ~ i n tbt 199.ls ~ E n a ~
icizmo (Rqumdy <h '°
s 10 pttcm i Ce.g..., Stooc, 2o;1er & Shupe. :-X::l-
·Jbt ~in g ~ of ~ i o n doorder deady ~ o t h e r ~ a.n~ -!so rom.roa."Lfy uwd t~ dis,.,
~ in
~ how •fJJJC tiomr a comcn ion disorder mq tinguishing bdw,m axnffSion disorda-s and trzorp .nic
1ht O'R1il l i f e ~ of a pariffl t. ~rut its a.act-
disturbmc.rs
q, catain cost in illness or disability..
► Th e~ £matt of mt ~'5timcrioo to l"lXUO!ffl
dmty tolhts1mp1 u1m ctth it~~ or
disorda simubted. Far cumple. littk oroo ..--z-.:;,'5
A Wife with •fits • awq or atrophy ofa•~ ·lim b ~ in coo-
WJ sion ~
aapti nr~a nd
long-ttmding CWL.
► Tht- JdectM Bll1ft
of the dys(uoaioo.
Asal~ noted .in
COD\U sioo hlind-
oess tbt aJlected
individual doa DO(
USlla0 , bump into
people or objecu,
and~ ~dtM~of~
musdcsan be used disolt lttrco n~~~ rwbla dtJI'
foe some ~ti a ~e-,~~
but not othm.
~ Under bypno m« aaRDlis (a dftpli lt statt induad
bydrup} tht srmptonn can PMYlly • J'ffltO\ tJ.
shifted, or randuad at tw tagFdion ol tbt thaa-
pilt- Similaet,.a pa'ICbi lhn1pdy awmacd from a
IOUDd lkq, DIIJ'. ......., belYc 10 mt a•ran..
i,,m-Jimb. •
 CHAP TE R 8 So'"'2JOfer,tt aftll !)isjociotrW o,si,,Jm
·ng their symptoms, feel thffll.Sdves to L._ ~
DISTINGUISHING CONVERSION FROM MALIN~E~- P.roduc1
of their symptoms, an are very Willinguctotht•. ~.
• d
ING AND FROM FACTITIOUS DISORDER Sometu~e' ums • • d .... il (Mal dit...-
them, often in .excru~iaung_ ew . . do~ & ~~
200 l, P· 109 ). When inconStstencies an their ~
of course, people do deliberatdy and consciously .re~gn
disability or illness. for these instances, the D~M d•5ttn· inted out, they are usually unpenurbed. Any 6eco ilt
guishes ~tween malingering and faaitious disorder on ~ th,,,,
gains .., ex~rienc e are by-products of the ,.,.. ~
the basis of the feigning ~rson's apparent goals. The r- d . ""n"thi....:
syrnptom s themselves an are not mvolvcd in . -'"""
malingering ~rson is intentionally producing ?r grossly lnobn~·
the symptoms. Bf contrast, per~ns who are lei:"
exaggerating physical symptoms and is mo~~ted by symptoms are indtned to be defens1vc, evasive, and ~
external incentives such as avoiding work or m1htary .se~-
cious when asked about them; they are ~ually rel~
vicc, obtaining financial compensation, or evading cruni •
nal pros«ution (APA, 2000; Maldonado & Spiegel, 2001 ). •
be examined and slow to talk about thelJ' S}'rnpto lo
In factitious disorder also, the person intentionally pro- the pretense be d~scovcred. Sho~d incons~ncics ~ .
duces psychological or physical symptoms (or both), but behaviors be pointed out, deliberate dcet1vcrs as a rule•)
there are no external incentives. Instead, the person's goal immediately become mo~c defe~sivc. Thus conversion :
is simpJy to obtain and maintain the personal benefits th~t order and deliberate faking of illness are considered 4 dis. t
playing the "sick role" (even undergoing ttpeated hospi- tinct patterns. ,'
talizations) may provide, including the attention and con·
cern of family and medical personnel. Frequently these TREATM £NT OF CONVERSION DISORDEI 0« . 1

patients surreptitiously alte.r their own physiology-for knowledge of how best to treat conversion disorder i ~
example, by taking drugs-in order to simulate various extremely limited, because no well-controlled studi~~ i
real illnesses. Indeed, they may be at risk for serious injury yet been conducted (e.g., Bowman & Markand. 2005; l
or death and may even need to be committed to an insti- Looper & Kirmayec, 2002). Some hospitalized patitnts ~
tution for their own protection. (Sec The World Around with motor conversion symptoms have been successfully;
Us 8.1 for a particularly pathological variation on this.) treated with a behavioral approach in which specificCJtr. i.
ln the past, severe and chronic forms of factitious disor .. cises are prescribed in order to increase movement or ~
der with physical symptoms were caJ]ed "Munchausen's walking, and then reinforcements arc provided when:
syndrome;' where the general idea was that the person patients show improvements (e.g., praise and gaining·{
ha<l some kind of "hospital addiction" or a "professional privileges). Any reinforcements of abnormal motor helm- ~
patient" syndrome. iors are removed in order to eliminate any sources of sec· ~
It is sometimes possible to distinguish between a con- ondary gain. In one small study using this kind of:
version (or other somatoform) disorder and malingering, treatment for ten patients, all had regained their abilityU> •
or factitiously"sick,, role-playing, with a fair degree of con .. move or walk in an average of 12 days, and for StVenri
fidencc, but in other cases it is more difficult to make the
the nine available at approximately 2-year follow-up, the
correct diagnosis. Persons engaged in malingering and
improvements had been maintained (Speed, 1996). Somt .
those who have factitious disorder are consciously perpe-
studies have used hypnosis combined with other prob- :
trating frauds by faking the symptoms of diseases or dis-
abilities, and this fact is often reflected in their demeanor. lem-solving therapies, and there arc some suggtstions ~
Individuals with conversion disorders are not consciously hypnosis, or adding hypnosis to other therapeutic ttdl· .
niques, can be useful (Looper & Kirmayer, 2002; Mocnt.
et al., 2003 ). .

DSM -IV- TR Body Dysmorphic Disorder .

Bodydysmorphicdisorda (BDD) is officiallydass~n:
Criteria for Factitious Disorder DSM-IV:~ (APA, 2000) as a somatofo~ diso rJ •.
because 1t involves preoccupation with certain asptct5
the body. People with BDD are obsessed witb sotrJ •
A. lntendonal produdlon or feigning of physical ·or
psydlotoskal sips of symptoms. P~vtd or imagined jl4w or flaws in their ap~r: •
L Motivation for the behavior Is to assume the sick role. 1:'1
15
• P~pat ion is so intense that it ca~ ~ :

C. l'belt,• IIO ectemal Incentives for the behavior (t.(.. s~gnificant distress and/or impairment in sooal or~
eca•..WC pin or ftddlns lept raponslbllltles. as Sift tional functioning. Although it is not considertd n _.,t<i«
In . . . .!'Ina). for the diagnosis, most people with BDD have corn~ill ,
checking behaviors (aach u checking their appt'~~
.,,,., ..,.,..,...,_,tlwDlapostle the mirror a,
....,,, ... ........ ldllolt, 1
c•lwlJ or luding or repairinl a ~·J
r,hl MJOO}. Ame, flaw). Another "'1' common symptom is avo1 ~ ~
tHdlflon.
~ ..... bem. of fear that other ~~ tbt"
~-· ...Ntf -.:l mcl be npulsed. In~ 11p o>
-----
m a r ~ • llolatect that ther lock themsd''d •