Please see attached.
Week 3
Respond to the following in a minimum of 175 words each question, post must be substantive responses:
How can the issues of race, ethnicity, and culture influence the assessment for and diagnosis of mental health disorders?
What steps do clinicians need to take to ensure they multicultural competence in the assessment process?
Respond to classmates in a minimum of 175 words each person, post must be substantive responses:
T.W.
How can the issues of race, ethnicity, and culture influence the assessment for and diagnosis of mental health disorders?
The issues of race, ethnicity, and culture influence the assessment for and diagnosis of mental health in a variety of ways. The first major influence is the belief in mental illness, the trust of other races, culture or ethnicity. Not every culture believes in depression, anxiety or other That could include inter race conflicts and not just across cultures. If the person is female they may only want a female therapist. If the client is Hispanic they may only trust a Hispanic person. The other issue is the lack of trust could lead to deception in the assessment. That could come in the form of omitting information or over exaggerating information.
What steps do clinicians need to take to ensure they multicultural competence in the assessment process?
The first thing a clinician can do is take the time to educate the client and the client’s support system. That could include showing the assessment, given some stats about the specific assessment. They can ask about the client’s concerns. If those concerns include race, ethnicity or cultural factors they can look at some possible systems such as if the assessment is online then the person in the room could be someone other than the clinician if that would help ease the clients anxieties.
Another multicultural competence that needs to be considered is language (grammar) and the meaning of words. We cannot assume everyone knows what certain words mean. The clinicial needs to check for understanding and not talk At the client. They need to explain, check the rate of speed when speaking, monitor tone of voice and keep asking if the client has any questions.
The length of the test: Clinician may need to chunk the assessment to consider brain capacity.
Another consideration is to share with the client and their support group that the results will be discussed and the interventions will also be discussed without anything being imposed on the client.
N.S
Cultural identity is at the heart of every thought, action and belief for all people, of any background which is why it is important for counselors to study and practice multicultural diversity. The issues that could influence assessment could include the mistrust of certain groups or traditional practices as stated in regard to individuals with strong ethnic identity. Beidel, D. C., Frueh, B. C., & Hersen, M. (2018) They may find that approaches offered by dominant culture are not to be trusted or are simply outside of deeply held beliefs or value systems.
Problems with diagnosing could occur when counselors are not fully aware of the natural cultural expression within groups and as a result they misinterpret responses as being more intense ,presenting in a more pathological manner than expected simply based on bias or inexperience. For example, in African American clients, schizophrenia is often misdiagnosed based on a cultural misunderstanding “due to the tendency for African Americans to endorse more psychotic symptoms during diagnostic assessments”. Beidel, D. C., Frueh, B. C., & Hersen, M. (2018
Steps towards multicultural competence could include ensuring the most appropriate kinds of assessment instruments and therapeutic techniques are utilized with consideration of every client’s unique cultural and world view. Clinicians could also benefit from knowing what they do not know, in regard to cultural heritage, the possible stress of assimilation to dominant culture and various spiritual perspectives. Beidel, D. C., Frueh, B. C., & Hersen, M. (2018)
Reference:
Beidel, D. C., Frueh, B. C., & Hersen, M. (2018). Adult psychopathology and diagnosis (8th ed.). Hoboken, NJ: John Wiley & Sons.
Chapter 5
Impact of Race, Ethnicity, and Culture on the Expression and Assessment of Psychopathology
L. Kevin Chapman, Ryan C. T. Delapp, and Monnica T. Williams
This chapter provides an overview and framework for understanding race, ethnicity, and culture as factors that affect adult psychopathology. Of primary interest are the assessment and treatment of psychopathology that integrates culturally salient values, ideologies, and behaviors into the mental health care of ethnic minorities. Moreover, the chapter is organized into two sections. In the first section, we present a model that highlights relevant multicultural factors that should be considered when working with ethnic minorities. The second section provides a discussion of how to effectively apply the knowledge of these multicultural factors when assessing or treating individuals with diverse ethnic backgrounds. Ultimately, the main objective of this chapter is to encourage mental health professionals to acknowledge the impact of race, ethnicity, and culture on adult psychopathology in order to optimize the efficaciousness of mental health services provided to ethnic minority individuals.
The existing literature has clearly demonstrated the importance of multicultural competency in the assessment and treatment of ethnic minorities. In particular, the relevance of ethnicity (or “a voluntaristic self-identification with a group culture, identified in terms of language, religion, marriage patterns and real or imaginary origins”; Bradby, 2012, p. 955) in adult psychopathology has been substantiated by evidence identifying disparities in prevalence rates, symptom presentation, and severity, as well as mental health service utilization across diverse ethnic groups. For example, Himle et al. (2009) found that most anxiety disorders (with the exception of post-traumatic stress disorder [PTSD]) were more prevalent among non-Hispanic Whites than among African Americans and Caribbean Blacks. However, despite their lower prevalence rates, researchers reported that African Americans and Caribbean Blacks experienced anxiety disorders that were greater in severity and more functionally impairing, which demonstrates how experiences with mental illness can vary by ethnicity. Moreover, ethnicity has been implicated as a differentiating factor in the diagnosis and treatment of schizophrenia (Fabrega et al., 1994; Gara et al., 2012).
These studies highlight the susceptibility of misdiagnosed schizophrenia in African American patients due to the tendency for African Americans to endorse more psychotic symptoms during diagnostic assessments. As a result, Gara et al. (2012) emphasize the importance of culturally sensitive diagnostic assessment tools by explaining how an inability to effectively discriminate schizophrenia and schizoaffective disorders can lead to poor treatment outcomes. Additionally, the relevance of ethnicity in adult psychopathology is bolstered by the findings of Alegria et al. (2007), who used data from the National Latino and Asian Study (NLAAS) to identify factors that influence the treatment-seeking behaviors of Latino individuals. Specifically, researchers found that age of migration, Latino ethnicity (e.g., Mexican, Puerto Rican), birth origin (e.g., U.S.-born, foreign-born), primary language spoken, and years of residency in the United States were all influential factors in the use of mental health services and the satisfaction with care received. Most notably, these findings highlight the impact of varied immigration statuses on the perspectives that ethnic minority individuals bring to the mental health arena. Overall, the aforementioned studies clearly underscore the need for multicultural competency in mental health professionals given that one’s self-identification with an ethnic heritage has proven to be a vital differentiating factor in the presentation of symptoms and treatment outcomes across diverse adult samples.
Relevance of Ethnic Identity and Acculturation in Adult Psychopathology
An understanding of the interaction between multicultural factors (e.g., ethnic identity, acculturation) and sociocultural factors (e.g., socioeconomic status, life stress) in ethnic minority patients has become undeniably germane to providing these individuals with effective mental health care. Prior to learning “how” to integrate the understanding of this interaction within assessment, diagnostic, and treatment practices, mental health professionals must possess the knowledge of “what” multicultural factors exist. Inasmuch, Carter, Sbrocco, and Carter (1996) proposed a theoretical model that acknowledges the role of ethnicity, or a “shared culture and lifestyle,” as a pivotal underlying construct in the epidemiology, symptom expression, and treatment of psychopathology in ethnic minority individuals (p. 456). Though initially created to explain variations of anxiety disorders in African Americans, the Carter et al. (1996) model can be utilized to more broadly understand the relationship between ethnicity and adult psychopathology by comprehending the salience of ethnic identity and acculturation in all ethnic minorities.
In particular, ethnic identity is a multifarious construct characterized by how people develop and maintain a sense of belonging to their ethnic heritage (Roberts et al., 1999). Important factors influencing a person’s ethnic identity include whether they personally identify as a member of an ethnic group, their sentiments and evaluations of the ethnic group, their self-perception of their group membership, their knowledge and commitment to the group, and their ethnic-related behaviors and practices (Burnett-Zeigler, Bohnert, & Ilgen, 2013). Extant literature has provided several models explaining the developmental stages of ethnic identity (Cross, 1978; Cross & Vandiver, 2001; Marcia et al., 1993; Phinney, 1989). Collectively, each model describes identity shifts between ethnic ambivalence (lack of interest or pride in one’s ethnic background), ethnic exploration (curiosity in one’s ethnic background potentially accompanied by a devaluing of other ethnic heritages), and multicultural acceptance (integration of commitment to one’s ethnic background and an appreciation for other ethnic heritages). Evidence supports the idea that individuals high in ethnic identity (i.e., closer to multicultural acceptance) typically have higher levels of self-esteem, develop more protective coping mechanisms, experience more optimism, and report less psychological symptoms (Chavez-Korvell, Benson-Florez, Rendon, & Farias, 2014; Roberts et al., 1999; Smith, Walker, Fields, Brookins, & Seay, 1999; McMahon & Watts, 2002; Williams, Chapman, Wong, and Turkheimer, 2012). Notably, the protective nature of a strong ethnic identity is not ubiquitous and may vary across ethnic minority groups. For example, Ai, Nicadao, Appel, and Lee (2015) compared the relationships between ethnic identity and diagnosis of major depressive disorder (MDD) among Chinese, Filipino, and Vietnamese American adult samples. Researchers found that higher levels of ethnic identity were related to lower likelihood of MDD among Filipino Americans and higher likelihood of MDD among Chinese Americans. Ethnic identity was unrelated to MDD in the Vietnamese sample. Though the buffering effects of ethnic identity are evident for some, such findings, along with other research (Yip, Gee, & Takeuchi, 2008), suggest that experiencing a strong sense of belonging to a native heritage can amplify the impact of culturally specific stressors (e.g., discrimination, social inequalities), thereby enhancing an individual’s focus on their differences from majority culture. Past literature has found that the stage of ethnic identity development, age, and level of perceived stress can attenuate the buffering influence of high ethnic identity (see review by Burnett-Zeigler et al., 2013).
Another relevant construct implicated in the Carter et al. (1996) model is acculturation, traditionally defined as the extent to which ethnic minorities adopt the values and participate in the traditional activities of mainstream culture. Recent re-conceptualizations of the acculturation process utilize a multidimensional perspective where ethnic minorities must reconcile discrepancies in their identity (the salience of one’s ethnic versus national identity), value system (individualism versus collectivism), language proficiency, cultural attitudes and knowledge, as well as cultural practices (Park & Rubin, 2012; Schwartz et al., 2013; Yoon et al., 2013).
According to a meta-analysis of 325 studies about the relationship between acculturation and mental health, Yoon et al. (2013) found that mainstream language proficiency was negatively associated with negative mental health, whereas endorsing an ethnic identity was positively related to positive mental health. Most importantly, these findings demonstrate how complex the relationship between acculturation and psychopathology can be, which emphasizes the need for mental health professionals to consider the relevance of each acculturation dimension (e.g., identity, language, value system, behaviors) when working with ethnic minorities. Furthermore, the acculturative stress of integrating disparities in ethnic and mainstream culture across these dimensions can result in difficulties adapting to mainstream culture and/or perceived rejection from one’s native heritage (Schwartz et al., 2013), which has been associated with psychopathology in ethnic minority adults (e.g., more eating-disorder symptoms (Van Diest, Tartakovsky, Stachon, Pettit, & Perez, 2013) and greater levels of depression (Ai et al., 2015; Driscoll & Torres, 2013; Jaggers & MacNeil, 2015; Park & Rubin, 2012). When confronted with such cultural disparities, extant literature has identified biculturalism, or the ability for ethnic minorities to effectively integrate elements of two cultural streams, as one of the most protective acculturation statuses against negative health outcomes (Schwartz et al., 2013). For example, Wei et al. (2010) found that high levels of bicultural competence (or the ability to navigate between two groups without undermining one’s cultural identity) among ethnic minority college students were protective against depressive symptoms despite experiencing high levels of minority stress.
Alternative acculturative statuses include strongly adhering to the mainstream culture and devaluing native heritage (assimilation), strongly adhering to the native heritage and devaluing the mainstream culture (separation), and exhibiting little interest in adhering to either cultural stream (marginalization; see Matsunga, Hecht, Elek, & Ndiaye, 2010; Yoon et al., 2013). Overall, the existing literature has yielded inconclusive findings clarifying the impact of acculturation on the mental health of ethnic minorities (see Concepcion, Kohatsu, & Yeh, 2013), which has been accredited to the multiple definitions of acculturation (e.g., time since immigration, language fluency, acculturation status) and examining this construct in few ethnic minority groups (Burnett-Zeigler et al., 2013; Yoon et al., 2013).
Aside from having knowledge of ethnic identity and acculturation, mental health professionals must also understand how these constructs interact to influence the psychopathology expressed in many ethnic minority individuals (Yoon et al., 2013). In referencing the Carter et al. (1996) model, African Americans who maintain a strong ethnic identity and are highly assimilated in the dominant culture are believed to endorse traditional beliefs of mainstream society (e.g., individualism) and exhibit symptom presentations consistent with the current diagnostic nomenclature. Notably, it is theorized that these individuals may feel conflicted by being acculturated to believe psychological treatment is effective while embodying a mistrust of societal systems in mainstream culture as a result of historically significant cultural experiences (e.g., perceived discrimination from individuals of the dominant culture). Similarly, Carter et al. (1996) conceptualized that African Americans low in ethnic identity yet highly assimilated will exhibit a traditional symptom presentation, but will be more willing to seek, persist through, and benefit from traditional treatment practices. In contrast, individuals high in ethnic identity who strongly de-identify with mainstream culture (separation acculturation status) represent a subset of ethnic minorities who may display unique symptom presentations and utilize culturally specific explanations for their symptoms, thereby resulting in a greater likelihood of misdiagnosed psychopathology. Further, these individuals are theorized to be less likely to seek treatment due to mistrust in and/or a limited knowledge of mental health care.
Although there is a dearth of literature devoted to examining the additive impact of ethnic identity and acculturation on adult psychopathology (Chae & Foley, 2010), several studies provide evidence supporting the broad application of the Carter et al. (1996) model across diverse ethnic minority groups. Burnett-Zeigler et al. (2013) examined the relationship among ethnic identity, acculturation, and the lifetime prevalence of mental illness and substance use in African American, Latino, and Asian samples. Results indicated that higher levels of ethnic identity, and not higher acculturation, were related to decreased lifetime prevalence of psychiatric illness and substance use for each minority group. Notably, higher acculturation (e.g., use of English language or social preference for individuals not in ethnic group) was associated with increased prevalence of depression in African Americans and Hispanics, increased bipolar diagnoses in Hispanics, and increased anxiety disorder diagnoses for all minority groups. Regarding substance use, higher acculturation was related to increased lifetime prevalence of alcohol and drug use among the Hispanic and Asian sample. These findings suggest that having a strong sense of pride and belonging to an ethnic heritage is protective; however, nondominant individuals who are unable to maintain cultural ties with their native heritage (e.g., first language, relationships with members of ethnic group) may be more susceptible to negative health outcomes.
Nascent literature has provided a more specific understanding of the interaction between these two constructs by utilizing acculturation statuses (e.g., integration, assimilation, separation) instead of a broad definition of acculturation (e.g., English literacy; time of residency). In particular, Matsunaga, Hecht, Elek, & Ndiaye (2010) examined the interaction between ethnic identity and acculturation status in Mexican-heritage adolescents living in the southwest region of the United States and found that an integration acculturation status was more prevalent than assimilation, as well as more predictive of a strong ethnic identification, which suggests that a strong ethnic identity and a successful integration of two cultures are closely associated. Furthermore, Chae and Foley (2010) found that high ethnic identity strongly predicted positive psychological well-being among Chinese, Japanese, and Korean Americans, whereas an assimilation acculturation status predicted poorer psychological well-being among Korean Americans. Also, researchers found that Asian Americans with an integration acculturation status experienced significantly higher psychological well-being compared with other acculturation statuses. Most importantly, these findings suggest that ethnic minorities who maintain a strong sense of belonging to their ethnic heritage (high ethnic identity) and who have successfully integrated the identities, value systems, and cultural practices of their native and mainstream heritages (integration) exhibit fewer clinical symptoms and more life satisfaction.
Relevance of Sociocultural Factors in Adult Psychopathology
Although an understanding of the aforementioned constructs is essential, it is equally important to examine the impact of other sociocultural variables that also exert a considerable degree of influence over the symptom presentation and treatment outcomes of ethnic minorities. Although extant literature has identified myriad variables that impact minority mental health, the current chapter solely focuses on socioeconomic status (SES), stressful life events, and age cohort, which were each identified by the Carter et al. (1996) model as important contributors to the mental health of ethnic minorities.
Researchers propose that SES can provide a more precise understanding of the relationship between ethnicity and adult psychopathology by focusing on the specific environmental elements that characterize each social class. Past literature has shown that high SES is related to better health outcomes. One study by Shen and Takeuchi (2001), examining the relationship between acculturation, SES, and depression in Chinese Americans, found that SES was a better indicator of depressive symptoms than acculturation and that high-SES individuals (i.e., high educational attainment and increased income) had better mental health outcome (i.e., fewer depressive symptoms) compared with low-SES individuals. These findings suggest that it is through the variance in SES and related variables (e.g., perceptions of stress, social support, and physical health) that acculturation may impact the mental health of nondominant individuals (Shen & Takeuchi, 2001). By contrast, nascent literature has begun to propose that the association between social class and mental health is much more complex in that evidence has supported that low-SES and/or foreign-born individuals are not automatically guaranteed poor health outcomes (John, de Castro, Martin, Duran, & Takeuchi, 2012). Rather, it has also been shown that middle class status may be associated with higher rates of affective disorders relative to lower and high classes (Prins, Bates, Keyes, & Muntaner, 2015). Given such findings, it suggests that mental health professionals should acknowledge the detrimental as well as the protective elements of one’s social class.
Also, the Carter et al. (1996) model identifies stressful life events as a contributor to the variability in the psychopathology of ethnic minorities. Though a comprehensive understanding of the multiple forms of stress (e.g., violence exposures, neighborhood context, poverty, etc) is beyond the scope of this chapter, extant literature pinpoints race/ethnic-based stress as influential to the mental health of ethnic minority individuals. In particular, Greer (2011) describes racism as “complex systems of privilege and power, which ultimately serve to threaten and/or exclude racial and ethnic minorities from access to societal resources and other civil liberties” (p. 215). As a result of such racial/ethnic injustice, many ethnic minorities are subjected to damaging race/ethnic-focused attitudinal appraisals (i.e., prejudice), race/ethnic-focused assumptions (i.e., stereotypes), and unjust treatment based upon their race/ethnicity (Greer, 2011).
Past studies have indicated that exposure to such race/ethnic-based experiences are strong indicators of mental health outcomes across diverse ethnic minority groups [e.g., discrimination was related to increased lifetime prevalence of generalized anxiety disorder in African Americans (Soto, Dawson-Andoh, & BeLue, 2011) and perceived discrimination was associated with increased anxiety, affective, substance abuse disorders among African Americans, Hispanic Americans, and Asian Americans (Chou, Asnaani, & Hofmann, 2011)]. Notably, empirical evidence suggests that perceived discrimination may be particularly salient to African American clients, given that several studies have found that African Americans endorse greater degrees of perceived discrimination in comparison to other ethnic minority groups in the United States (Cokley, Hall-Clark, & Hicks, 2011; Donovan et al., 2013). Overall, when utilizing ethnic identity and acculturation to gain insight into the culturally specific worldviews of nondominant individuals, it is imperative that mental health professionals also examine the occurrence and impact of race/ethnic-based stressors on the psychopathology of ethnic minorities.
Finally, the Carter et al. (1996) model discusses the relevance of age cohort in the manifestation of psychopathology in ethnic minorities. The evolution of the “social, economic, and political climate” in the United States has yielded diverse experiences across generations of ethnic minorities in this country, thereby impacting the meaning of ethnicity for each generation (Carter et al., 1996, p. 460). In the context of each ethnic group, there are different historical details separating each generation; however, the impact of age cohort on psychopathology remains a relevant consideration. In general, existing literature has implicated intergenerational disparities in perceived racial discrimination (Yip et al., 2008), ethnic identity (Yip et al., 2008), acculturation status (Buscemi, Williams, Tappen, & Blais, 2012), and lifetime prevalence of psychiatric illness (Breslau et al., 2006) across the adult lifespan. One study particularly relevant to this chapter’s discussion of the Carter et al. (1996) model examined the protective and/or exacerbating nature of ethnic identity in the relationship between racial discrimination and psychological distress in Asian adults (Yip et al., 2008). Results indicated that ethnic identity appeared to buffer the negative impact of racial discrimination on the psychological distress for adults aged 41–50 years, yet exacerbate the effects of racial discrimination for adults aged 31–40 years and 51 and older. In an attempt to explain these findings, Yip et al. (2008) theorize that the former age cohort is more likely to have a stable lifestyle with more coping mechanisms for stress, whereas the latter age cohorts may characterize adults who are in the exploration phase of their ethnic identity, which, therefore, heightens their sensitivity to being unfairly treated on the basis of their race/ethnicity. Furthermore, the parent–child relationship is another important way that intergenerational differences can impact adult psychopathology, especially for immigrant families (Kim, 2011; Vu & Rook, 2012).
In a study examining intergenerational acculturation conflict and depressive symptoms among Korean American parents, Kim (2011) found that greater discrepancies in cultural values between parent and child (greater intergenerational conflict) were related to increased parental depressive symptoms—an association more pronounced in mothers than in fathers. It was proposed that the cultural expectations of the Korean mother (e.g., to be a “wise and benevolent” primary caregiver) was conflicted by an incongruence with the value system of mainstream culture (Kim, 2011, p. 691). Collectively, such findings provide evidence that the Carter et al. (1996) model elucidates culturally specific considerations for psychological distress among diverse ethnic minorities.
Expression/Assessment of Psychopathology
Aside from the administration of culturally sensitive assessment tools to aid in the accurate diagnosis of psychopathology among ethnic minority patients, the current literature has implicated cultural factors endemic to ethnic groups that may influence the expression of their symptomology. The following section presents a general overview of how factors, such as stigma surrounding mental illness and perceived discrimination, impact various forms of symptom expression among non-Western and Western ethnic groups.
Expression of Psychopathology Differs Across Cultural Groups
It is often unclear how symptom profiles may differ between ethnic groups when typical research studies use structured instruments, based on an a priori set of questions believed to exemplify the disorder under investigation. Measures based on Western notions of prototypical symptoms will fail to capture cultural differences in the expression of all disorders. Thus, variations in symptom patterns are often overlooked or misunderstood. Such misunderstandings affect how we, in turn, conceptualize even seemingly well-defined disorders. The DSM-5 recognizes several cultural concepts of distress or mental disorders that are generally limited to specific cultural groups for certain dysfunctional and/or distressing behaviors, experiences, and observations (American Psychiatric Association, 2013).
Many culture-bound syndromes are likely unrecognized variations of common Western ailments. For example, susto is a folk illness seen in many Latin American and Native American communities that is attributed to having an extremely frightening experience. Although it is historically translated as “soul loss,” a closer meaning to this may actually be loss of “vital force,” as the soul is typically not thought to have actually left the body until death (Glazer, Baer, Weller, Garcia de Alba, & Liebowitz, 2004). People afflicted with susto may have symptoms that include nervousness, loss of appetite, insomnia, listlessness, despondency, involuntary muscle tics, and diarrhea. The symptoms of susto are actually quite similar to PTSD, which includes anxiety, avoidance, dissociation, jumpiness, sleep disturbances, and depression. Loss of “vital force” could resemble the fatigue and anhedonia, which may be a part of depressive symptoms within PTSD. Additionally, feeling as if one’s soul has been lost may be an idiom of distress for dissociation. Therefore, the concept of susto as a culture-bound syndrome may be better conceptualized as a culture-specific description of PTSD itself.
Interestingly, Latin American folk treatments for the disorder include elements of exposure-based therapies for PTSD (e.g., Williams, Cahill, & Foa, 2010). During the treatment ritual, the individual afflicted with susto must recount their terrifying experience while lying on the axis of a crucifix on the floor. Fresh herbs are swept over the afflicted individual’s body while the folk healer says a series of healing prayers (Gillette, 2013). If the first session is not effective, the process is repeated every third day until the patient is recovered. This repeated recounting process is a critical active ingredient in prolonged exposure and cognitive processing therapy, both highly effective treatments for PTSD, which likely accounts for some of the effectiveness of this folk remedy. Sugar, water, and tea may also be used to treat symptoms of chronic susto (Glazer et al., 2004), and in fact herbs used in traditional Mexican medicine have been found to possess anxiolytic effects (Herrera-Ruiz et al., 2011). In terms of conventional treatment for susto, because it is a folk illness, with roots deep in the Hispanic culture, patients may not believe they can be cured by modern methods, and therefore may be less likely to seek mental health care and less likely to believe they can be helped by Western treatments (Gillette, 2013). However, it is worth noting that effective folk remedies for susto have been available for centuries, whereas modern psychological treatments like prolonged exposure were developed relatively recently.
Another example of the connection between DSM disorders and culture-bound syndromes can be seen in the enigmatic ailment called koro. Though uncommon in Western cultures, koro is characterized by anxiety over the possibility of one’s genitalia receding into the body, resulting in infertility or death (Chowdhury, 1990). To prevent any envisioned shrinkage or retraction of the genitals, a koro sufferer will perform certain behaviors (i.e., pulling of genitals, spiritual rituals, securing genitals to prevent retraction) intended to reduce or eliminate this risk. Obsessive-compulsive disorder (OCD) is characterized by distressing and typically implausible obsessions, with compulsions designed to reduce the anxiety caused by the obsessions. Davis, Steever, Terwilliger, and Williams (2012) note the possibility that koro is simply a form of OCD, as an alternative to the current conceptualization as a culture-bound syndrome or cultural concept of distress. The most salient feature of koro concerns the anxiety surrounding the retraction and shrinkage of genitalia. The degree to which this distress can impair the daily functioning of those with koro has marked similarities to the construct of obsessions in OCD. This, coupled with the improbability of one’s genitalia actually receding into one’s body for good, makes it possible to categorize this fear as an implausible obsession.
Sexual obsessions are extremely common in OCD worldwide (Williams & Steever, 2015), but these types of thoughts are considered taboo or embarrassing in most cultures. Thus, the stigma and shame attached to the experience of sexual symptoms of OCD are exceptionally distressing (Glazier, Wetterneck, Singh, & Williams, 2015). Furthermore, Bernstein and Gaw (1990) note that sexual identity questions and conflicting feelings about sexuality are common in the experience of koro. Similarly, approximately 10% of treatment-seeking OCD patients report concerns about their sexual identity as a main concern (Williams & Farris, 2011). In OCD, these worries often manifest as fears of experiencing a change in sexual orientation, which is strikingly similar to the worries reported to underlie many cases of koro. Finally, koro has been shown to respond well to behavioral psychotherapy and medications like selective serotonin reuptake inhibitors (SSRIs; Buckle, Chuah, Fones, & Wong, 2007). These same treatments have long been the preferred method of treatment for OCD and its subtypes. Thus, koro is likely simply a cultural variant of OCD.
Although listed in the DSM-5 as a cultural concept of distress, neurasthenia, or shenjing shuairuo, is currently a recognized mental disorder in the World Health Organization’s International Classification of Diseases (ICD-10) and in the Chinese Classification of Mental Disorders. Traditional Chinese medicine describes shenjing shuairuo as a depletion of vital energy and reduced functioning in critical internal organs. The Chinese Classification of Mental Disorders considers it a mental disorder that may include weakness, emotional symptoms, excitement symptoms, tension-induced pain, and sleep disturbances. Neurasthenia has been considered a somatic illness, similar to or the same as MDD, but involving culturally sanctioned idioms of distress.
Likewise, there are many conditions that may be considered Western culture-bound syndromes, due to their infrequency or absence in other cultures. These may include anorexia nervosa, substance use disorders, chronic fatigue syndrome, animal hoarding, attention deficit hyperactivity disorder, Munchhausen by proxy, premenstrual dysphoric disorder, dissociative identity disorder, and even type A personality. Many maintain that all psychiatric disorders, regardless of culture, are always culturally influenced constructs. Still others assert that the DSM is itself a culture-bound document and question whether it should be used at all outside its country of origin (Nadkarni & Santhouse, 2012).
Expression of Psychopathology Differs Within National Borders
It may be misleading to present cultural differences in psychopathology as an issue only applicable to those in non-Western or developing nations. The expression of psychopathology can and does differ among US ethnic groups that may be considered fairly acculturated (i.e., that share a common language and national borders).
For example, African Americans have been an integral part of American life for centuries, yet notable differences in psychopathology are nonetheless evident. An investigation of OCD in African Americans (Williams, Elstein, Buckner, Abelson, & Himle, 2012) found obsessive-compulsive concerns in five major areas, including contamination and washing, sexual obsessions and reassurance, aggression and mental compulsions, symmetry and perfectionism, and doubt and checking. These dimensions are similar to findings of studies in primarily White samples (i.e., Bloch et al., 2008). However, African Americans with OCD report more contamination symptoms and were twice as likely to report excessive concerns with animals compared with European Americans with OCD.
These notable cultural differences are consistent with findings among nonclinical samples (e.g., Thomas, Turkheimer, & Oltmanns, 2000). Williams and Turkheimer (2007) studied racial differences in OCD symptoms and found that a nonclinical sample of African Americans scored significantly higher on an animal attitude factor than European Americans, meaning they had greater concerns about animals, and it was determined that cultural factors explained this difference. It was hypothesized that the Western perspective of animals as pets is more socially acceptable among European Americans than other cultures which are more likely to regard animals as a source of food or vehicle for labor. Other cultural differences may relate to earlier practices such as the use of dogs as a means to hunt slaves or attack protesters during the Civil Rights era. This is consistent with recent work suggesting that African Americans may experience greater phobias of animals (Chapman et al., 2008). As such, cultural differences are plausible contributing factors for increased animal sensitivity among those with OCD. Fear of being misunderstood was also more frequently endorsed by African Americans with OCD (Williams et al., 2012). An obsessive need to be perfectly understood could be a unique finding for African Americans related to fears of appearing unintelligent, resulting in stereotype compensation—an intentional effort to present oneself in a counterstereotypical manner (Williams, Turkheimer, Magee, & Guterbock, 2008). Finally, one epidemiological study found that that OCD symptom severity was significantly correlated to racial discrimination but not other forms of discrimination, such as discrimination based on gender or sexual orientation.
Prevalence Rates May Differ for Cultural Reasons
Prevalence rates of various disorders may also differ for cultural reasons. For example, the National Survey of American Life (NSAL) conducted a comprehensive nationwide study of African American and Caribbean Blacks. They interviewed a large number of adults (n = 5,191) and adolescents (n = 1,170) in their homes, using professionally trained, ethnically matched interviewers. Their study was the first to examine the prevalence, age of onset, and gender differences in a number of mental disorders in a nationally representative Black sample (Taylor, Caldwell, Baser, Faison, & Jackson, 2007). Findings were consistent with previous research indicating that anorexia nervosa is rare among African Americans. In fact, not a single woman in the study met criteria for anorexia in the previous 12 months, and there were no reports at all of anorexia in Caribbean adults. These findings indicate that Black Americans are at lower risk of anorexia than their White counterparts. Likewise, a related study found that Hispanic and Asian American female adults experienced similarly low rates of anorexia nervosa (Franko, 2007). The authors of that study suggested that detection and barriers to treatment may be a factor in the lower rates, but there has been very little research focused on what cultural factors may differentially protect minorities from this disorder and yet promote it in European Americans.
Another way in which culture may impact psychopathology can be found in the frequencies of specific symptoms within a disorder. For example, Chapman and colleagues (Chapman et al., 2008, 2011) found that both African American college students (2008) and African American adults from the community (2011) reported more animal and social fears than did their European American counterparts. These results indicate the need for further exploration of cultural factors and their impact on psychopathology.
Stigma and Somatization of Distress Across Cultures
Although there is a general tendency toward somatization across all cultures, ethnic minority individuals in the United States appear more likely to express psychological distress through bodily symptoms for two primary reasons: (1) as compared with European Americans, there is a higher level of stigma associated with mental illness and, therefore, physical symptoms are more socially acceptable; and (2) there is more holistic conceptualization of the person, and, therefore, less of a distinction between mind and body among ethnic minorities (USDHHS, 2001).
For many groups there is considerable stigma attached to being afflicted by mental illness, and thus clients from these groups may be more comfortable reporting physical symptoms over affective and cognitive symptoms. One study of African Americans found that concerns about stigma prompted most mental health care consumers to initially avoid or delay treatment, and once in treatment, they commonly faced stigmatizing reactions from others (Alvidrez, Snowden, & Kaiser, 2008). Hunter and Schmidt (2010) developed a model that incorporates stigma, racism, and somatization into the expression of anxiety in African Americans. The emphasis on physical illnesses over mental illness in African American communities is thought to be related to physical explanations of somatic symptoms of anxiety, including attributing these to conditions like cardiovascular disease, and subsequent help-seeking oriented to these explanations. In particular, anxiety disorders among African Americans are likely to include both fears related to minority status and catastrophic interpretations of somatic symptoms. They propose that these differences, because of their implications for measurement and diagnosis, can explain reduced detection of certain anxiety disorders in African Americans compared with European Americans.
Western models of health and illness often depict a fragmented representation of the person to conceptualize mental and physical processes. For example the mind and body are regarded as separate (called dualism), and then the mind is even further divided in many common models (e.g., psychodynamic personality model of id, ego, and superego; cognitive behavioral therapy’s affective, behavioral, and cognitive components). However, many cultures do not make a distinction between the mind and body. Additionally, many cultural traditions recognize the spirit as an integral part of the person, inseparable from the mind and body (e.g., Parham, 2002). Thus, omitting this component will reduce the salience of the treatment in such clients.
Spirituality and Religion
Spirituality and religious beliefs can be the most important facets of a person’s identity, and thus appreciating spiritual and religious diversity is essential to multicultural competency. In the United States, 89% of adults say they believe in God, 77% have a religious affiliation, and 53% say their beliefs are very important to their lives (Pew Research Center, 2015). When help is sought, clients typically look for someone who shares the same values. Thus, therapists will be viewed as more credible in the community if they are competent in religious/spiritual issues.
Devout or orthodox members of most religious traditions tend to have negative perceptions of the mental health professions, distrust therapists, and under-utilize mental health services. This is in part because traditionally the field of psychology has been hostile toward religion. Psychologists are more secular and less religious than the population at large, and therapists have tended to reject organized religious involvement; thus, there is a religiosity gap between mental health providers and the US majority. As a result, building trust may be challenging when working with devout clients, and, in such cases, learning about a client’s religious tradition is essential to building rapport. At the very least, it is essential for therapists to avoid interventions that conflict with normative religious beliefs, and at best therapists can incorporate a client’s religious practices into treatment. Therapists need to be able to understand individuals and their beliefs within their cultural context (Richards, Keller, & Smith, 2004).
Over the past few years, an uneasy truce has developed between psychology and religion. This is due in part to new research that shows the important role of religion in mental health and well-being. For example, meditation and prayer are correlated with reduced blood pressure and pulse, lower endocrine activity, and lower metabolism. Religious involvement has also been shown to buffer against emotional difficulties, such as depression and anger. Thus a variety of psychological and spiritual interventions may be appropriate with religious clients, depending on the client, the nature of the problem, and the therapist’s religious knowledge.
Racism and Discrimination
As previously noted, the experience of being a stigmatized ethnoracial minority is a common phenomenon across cultures, with profound implications for mental health. This includes visible minorities in the United States and Canada, as well as ethnic and cultural groups in other countries, such as Blacks in the United Kingdom, Turks in Germany, and the Dalit in India. Many studies have established a link between discrimination and mental health outcomes. In the United States, African Americans experience the greatest amount of racial discrimination, followed by Asian Americans and Hispanic Americans (Chou et al., 2012). Perceived discrimination has been found to be negatively correlated with mental health, and the effects seem to be strongest (most detrimental) for Asian Americans, followed by Hispanic Americans, followed by African Americans (Cokley et al., 2011).
In addition to overall psychological distress, racism and discrimination have been associated with several specific mental health problems, including stress (Clark, Anderson, Clark, & Williams, 1999), depression (Banks & Kohn-Wood, 2007; Torres, Driscoll, & Burrow, 2010), anxiety (Hunter & Schmidt, 2010), binge drinking (Blume, Lovato, Thyken, & Denny, 2012), PTSD (Pieterse, Todd, Neville, & Carter, 2012), and psychosis (Berger & Sarnyai, 2015). A strong, positive ethnic identity has been shown to be a potential protective factor against psychopathology among minorities (e.g., Williams, Chapman, et al., 2012), except when discriminatory events are severe (Chae, Lincoln, & Jackson, 2011). Failure to understand the role of racism and discrimination limits our understanding of mental health in stigmatized people groups.
Focusing specifically on the link between racism and PTSD can help us to understand how Eurocentric models may sometimes be inadequate for identifying distress in minority populations. The criteria for a PTSD diagnosis implies that a traumatizing event must involve a threat to an individual’s physical well-being. Although this description may address many forms of ethnoracially motivated traumatic events, it does not take into account how ongoing lower levels of racism that can lead to a general sense of distress and uncontrollability (Carter, 2007). These experiences, though they may not be physical in nature, attack the individual’s identity and force the person to re-experience traumas associated with their culture’s history (Helms, Nicholas, & Green, 2010).
Previous editions of the DSM recognized racism as trauma only when an individual met criteria for PTSD in relation to a discrete racist event. This is problematic given that many minorities experience cumulative experiences of racism as traumatic, with a discrete event acting as “the last straw,” triggering trauma reactions (Carter, 2007). Thus, current conceptualizations of trauma as a discrete horrific event may be limiting for minorities. Recent changes to the DSM may open the door for wider recognition of racism-related trauma. It is now within criteria that a person can have PTSD from learning about a traumatic event involving a close friend or family member, or if a person is repeatedly exposed to details about trauma (APA, 2013). This could encompass trauma resulting from ongoing racial stressors (Malcoun, Williams, & Bahojb Nouri, 2014).
Moreover, existing PTSD measures aimed at identifying an index trauma fail to include racism among listed choice response options, leaving such events to be reported as “other” or made to fit into an existing category that may not fully capture the nature of the trauma (e.g., physical assault). This can be problematic since minorities may be reluctant to report experiences of racism to European American therapists (Carter, 2007), who comprise the majority of mental health clinicians in the United States. Minority clients also may not link current PTSD symptoms to a single experience of racism if their symptoms relate to cumulative experiences of discrimination.
Bryant-Davis and Ocampo (2005) noted the similar courses of psychopathology between rape victims and victims of racism. Similar to rape victims, race-related trauma victims may respond with dissociation or shock, which can prevent them from responding to the incident in a functional manner. Victims may then feel shame and self-blame because they were unable to respond or defend themselves, which may lead to self-blame or self-destructive behaviors (Bryant-Davis & Ocampo, 2005). In the same investigation, a parallel was drawn between race-related trauma victims and victims of domestic violence. In both situations, survivors may feel shame over allowing themselves to be victimized.
Language and Symptom Expression
Another influence on symptom expression is the language used by clinician and client. For example, Diaz et al. (2009) examined the influence of language in the diagnosis of major mental disorders. A total of 259 bilingual Latino, monolingual English-speaking Latino, and European American adults with a history of MDD or psychotic symptoms were compared using structured interviews. Compared with European Americans and monolingual English-speaking Latinos, bilingual Latinos had significantly higher rates of diagnosed MDD and significantly lower levels of mania. No significant differences were found between monolingual English-speaking Latinos and European Americans. Between the three study groups, there was no significant difference in level of functioning, psychotic symptoms, or severity of depression. The authors concluded that the diagnostic process is affected by the combination of culture and language, notably being bilingual English/Spanish speaking. Thus, there appears to be an important effect of language on the report and diagnosis of psychopathology (Malgady & Constantino, 1998).
Treatment Issues
As the US continues to diversify, the understanding of the role of culture, race, and ethnicity in treatment remains paramount and is essential to culturally proficient work with ethnic minority patients. In the following section, a discussion of how such factors can influence various domains of the treatment process (e.g., therapeutic alliance, clinical judgments, and client perspectives) is presented. It is worth noting that the following treatment considerations are not comprehensive, but rather a general overview of how acknowledging the impact of certain cultural factors when working with ethnic minority patients can enhance the efficiency and effectiveness of treatment.
Clinician and Client Interplay
As noted in the previous edition, ethnic minority clients report feeling more comfortable discussing psychological problems with someone of the same ethnoracial background (for review, see Chapman, DeLapp, & Williams, 2014; Jackson et al., 2004), and they may answer questions about symptoms differently when this match is present (e.g., Williams & Turkheimer, 2008). Ethnic minority clients may perceive their counseling experience to be more effective when they are ethnoracially matched (Lee, Sutton, France, & Uhlemann, 1983), and non-Hispanic White clients may feel more comfortable with someone of the same ethnoracial group (Davis, Williams, & Chapman, 2011). Matching has been shown to strengthen the therapeutic alliance and improve retention (Flicker et al., 2008). However, cultural matching is not always possible due to a lack of availability of a clinician of the same ethnicity as the client, and it may not be desirable from the client’s perspective (e.g., could be perceived as “forced segregation”; Pole, Gone, & Kulkarni, 2008). Moreover, cross-cultural understanding of the client–therapist relationship may be enhanced by examining dynamics and issues surrounding race. Thus cross-cultural training is essential for all clinicians (Miller et al., 2015).
Cultural traditions vary in relation to the manner in which clinicians are regarded. Many consider therapists as authority figures and will feel uncomfortable challenging or disagreeing with their clinician. For example, when a Japanese client enters a consulting room, it is common for the client to just sit very tensely in front of the therapist and calmly answer questions. Japanese clients typically want to perform ideally, and this is reflected in therapist–client relationship. Clients tell the therapist their issues, and then just wait for the therapist to analyze them. Clients expect the therapist to tell them what to do. From a Western viewpoint, this can be seen as dependent, but it is actually a way for Japanese people to show respect by giving power to those in authority. Non-Hispanic White therapists can find it difficult to work with Japanese clients if the therapist is not aware of the power dynamics within the Japanese culture. When the Japanese utilize psychotherapy services, they generally apply Japanese methods of forming relationships, creating a hierarchical relationship between client and therapist. A Japanese client was assessed by a Western therapist without this understanding and the therapist believed the client had no sense of self, describing the client as passive, needy, and repressed. Japanese clients sometimes appear helpless and this might be misinterpreted as playing a victim role. However, from the client’s view, it is considered culturally appropriate (Nipoda, 2002). This example also illustrates how cultures differ in terms of what they consider to be the role of the therapist or healer. For example, within the Afrocentric framework, the essence of all things is spiritual. The spirit is energy and life force in each person, which constitutes a self-healing power. Thus, therapy becomes a process or vehicle in which individuals are helped to access their own self-healing power (Parham, 2002).
Role of Stereotypes, Biases, and the Clinician’s Culture
Although most clinicians are now receiving some multicultural education in their training programs (Green, Callands, Radcliffe, Luebbe, & Klonoff, 2009), practical skills for working with members of specific minority groups are often not included. When clinicians and researchers lack the needed skills and education for effective cross-cultural interactions, they may rely on a color-blind approach. Color-blindness is the ideology that different ethnoracial groups should all be treated the same, without regard to cultural differences (Terwilliger, Bach, Bryan, & Williams, 2013). Minorities are often treated as if they lack characteristics that make them different from the dominant majority. Although the intent of color-blindness is to promote fairness, it often causes confusion and can paradoxically increase prejudice (e.g., Richeson & Nussbaum, 2004). When the idea of “treating everyone the same” is proposed, it is typically from the perspective of the dominant majority, implying that clients should be treated as if they were culturally non-Hispanic Whites (Terwilliger et al., 2013).
From a clinical standpoint, color-blindness could result in negative consequences for an ethnic minority client if a therapist were to suggest that the client engage in behaviors that are generally considered adaptive within European American psychological tradition but which may in fact be culturally incongruent outside of that tradition. For example, a therapist may encourage an adult client to move out of the parents’ home and find his or her own apartment to assert autonomy. But in more collectivistic cultures, it may be abnormal for unmarried children to move out. Thus such an event could potentially result in a family crisis, conflict, and loss of needed emotional support. The goal, therefore, is not to treat participants as if they were European American, but as they should be treated based on the norms and customs of their particular culture. This approach, called multiculturalism, embraces the differences, strengths, and uniqueness of each cultural group (Terwilliger et al., 2013; Williams, Tellawi, Wetterneck, & Chapman, 2013).
Another issue of which clinicians must be aware concerns preconceived notions about clients based solely on ethnic group membership, or pathological stereotypes (Williams, Gooden, & Davis, 2012). These are generalizations about people used as a means of explaining and justifying differences between groups and thereby using these differences to oppress the “out-group.” Social status or group position determines the content of stereotypes, and not actual personal characteristics of group members (Jost & Banaji, 1994). Groups that have fewer social and economic advantages will be stereotyped in a way that seemingly explains disparities, such as lower employment or higher illiteracy rates. Although disadvantaged group members may have greater difficulty finding a job due to in-group favoritism, discrimination, and institutional racism, the disadvantaged group member is characterized as unmotivated (could have found a job if he looked hard enough), unintelligent (not smart enough to have that job), lazy (would rather take handouts than work), and criminal (will steal rather than work) (Williams, Gooden, & Davis, 2012).
It is important to understand that pathological stereotypes about cultural groups are unfair and inaccurate. Furthermore, all members of a society are affected by the negative social messages that espouse these stereotypes, casting disadvantaged groups in a negative light (Devine & Elliott, 1995). When we uncritically accept these negative messages, racism follows, even from professionals who mean well. This can lead to harmful, discriminatory behaviors toward clients, which may be conscious or unconscious, and overt or covert.
Perhaps the most common act of discrimination by clinicians is what is termed as a microaggression (Sue et al., 2007). A microaggression is a brief, everyday exchange that sends denigrating messages to a target simply because they belong to a racial minority group. Microaggressions are often unconsciously delivered in the form of slights or subtle dismissive behaviors. The target of a microaggression is often forced to ascertain whether another individual did in fact, perpetrate a discriminatory act. This attributional ambiguity is inherently stressful and is different from an overt discriminatory act, which is more easily identified and explained. As such, the influence of racial microaggressions on stress and anxiety may lie in the uncertainty generated from such interactions (Torres, Driscoll, & Burrow, 2010). One study found that racial microaggressions directed against African American clients was predictive of a weaker therapeutic alliance with White therapists. This, in turn, predicted lower ratings of general competence and multicultural counseling competence, and, unsurprisingly, lower counseling satisfaction ratings. Racial microaggressions had a significant indirect effect on client ratings of the counseling competence of White counselors through the therapeutic working alliance (Constantine, 2007).
It is important to understand that microagressions can be particularly harmful to vulnerable clients, who may already feel stigmatized and exposed even attempting therapy. Minority clients may find it difficult to respond to such remarks in counseling situations due to self-doubt and power dynamics. These problems contribute to feelings of distance from the therapist, unwillingness to disclose sensitive information, and early termination from treatment. Thus, clients may be unable to overcome the condition for which they sought help due to undesirable therapist factors. The degree of harm therapists may cause in this manner is unknown and likely underestimated (Constantine, 2007).
Culture as an Integral Part of Assessment
Americans are socialized not to acknowledge race and ethnicity, due in part to concerns of appearing biased or racist (Gaertner & Dovidio, 2005). However, this avoidance contributes to difficulty in recognizing, discussing, and adapting to cultural differences (Terwilliger et al., 2013). Many European American therapists are uncomfortable discussing race in cross-racial therapeutic dyads (Knox et al., 2003). However, therapists actually have more success working cross-culturally when they address differences directly. Raising the issue of race early in the therapeutic relationship conveys cultural sensitivity and may address clients’ concerns about a racially different counselor. When counselors communicate their own cultural background and acknowledge their client’s cultural values, clients are more likely to see their counselor as credible and feel more relaxed in therapy (Owen, Tao, Leach, & Rodolfa, 2011). Culturally competent counselors are aware of how their own cultural backgrounds and experiences influence their attitudes and values surrounding psychological processes, and this recognition enables them to better access the client’s needs (Delsignore et al., 2010).
Thus, it is important that clinicians understand culture-specific differences, which can range from amount of eye contact to specific idioms of psychological distress. Mental health professionals must make culture an integral part of each assessment, as it influences patterns of communication between clinician and patient and subsequent diagnostic and treatment outcomes (Alarcón et al., 2009). There are too many different groups for any one person to have an in-depth understanding of all, so clinicians should at least receive training specific to the ethnoracial groups most commonly served, and seek additional information and consultation when confronted with clients from completely foreign cultures.
In its ongoing effort to more widely recognize cultural context, the DSM-5 now includes a cultural formulation interview guide designed to help clinicians assess cultural factors influencing client perspectives on their symptoms and treatment options. It includes questions about client background in terms of culture, race, ethnicity, religion and geographical origin. The interview facilitates the process for individuals to describe distress in their own words and then relate this to how others, who may not share their culture, see their difficulties. This gives the clinician a more comprehensive basis for diagnosis and care, and may be a good starting point for those clinicians working with ethnically different clients.
Mistrust of Medical Institutions and Establishment
According to the US Surgeon General, “research documents that many members of minority groups fear, or feel ill at ease, with the mental health system” (NIH, 1999). African Americans have greater distrust of the medical establishment and mental health care, many believing that medical institutions hold racist attitudes (Gamble, 1993; Whaley, 2001). Negative perceptions may be rooted in historical abuses of slaves, who were often used to test and perfect medical procedures before they were attempted on Whites (Gamble, 1997).
The most well-known example of such abuses is The Tuskegee Study of Untreated Syphilis in the African American Male. This is the longest nontherapeutic experiment on human beings in medical history. Begun in 1932 by the United States Public Health Service (USPHS), the study was designed to determine the natural course of untreated syphilis in 400 African American men in Tuskegee, Alabama. The research subjects, who had syphilis when they were enrolled in the study, were matched against 200 uninfected subjects who served as controls (Heintzelman, 2003).
The subjects were recruited with misleading promises of “special free treatment,” which were actually spinal taps done without anesthesia to study the neurological effects of syphilis, and they were enrolled without informed consent. The subjects were denied antibiotic therapy when it became clear in the 1940s that penicillin was an effective treatment for the disease. On several occasions, the USPHS actually interfered to prevent subjects from obtaining treatment elsewhere (Heintzelman, 2003).
In many cases, the infected subjects passed the disease to their wives and subsequently newborn babies. Over 100 people, died directly from advanced syphilis. In August 1972 an investigatory panel found the study was ethically unjustified and that penicillin should have been provided. The National Research Act, passed in 1974, mandated that all federally funded proposed research with human subjects be approved by an institutional review board (IRB). By 1992, settlement payments of approximately $40,000 were made to survivors. President Clinton publicly apologized on behalf of the federal government to the handful of study survivors in April 1997 (Heintzelman, 2003).
Many African Americans see the Tuskegee Study as representative of much current medical research even today (Freimuth et al., 2001). For instance, one study examined attitudes toward biomedical research across four ethnically diverse adults samples and found that African Americans endorsed more fear of participation in research than non-Hispanic White adults, which suggests that a cultural mistrust of research remains salient among African Americans (Katz et al., 2006). Most importantly, in cases where ethnic minorities appear hesitant or distrusting of mental health care, it is important for mental health professionals to remember the historical significance of a cultural mistrust in health care systems. Cultural knowledge of institutional abuses, combined with regular experiences of racism, maintains cultural mistrust surrounding health care.
Lack of Awareness Can Result in Misdiagnosis
Evidence shows that minorities are often misdiagnosed, due to the factors described previously. These include:
· Misuse of assessment instruments that are considered to be “gold standards.”
· Diagnostic criteria based on Eurocentric observations and conceptualizations, resulting in missed or misunderstood symptoms.
· Research findings based on Eurocentric diagnostic criteria, providing less helpful information about psychopathology in non-White populations.
· Lack of adequate multicultural training for clinicians, often resulting in a problematic color-blind approach.
· Pathological stereotypes about members of specific cultural groups that affect clinician judgments.
· Poor therapeutic working alliance due to lack of cultural awareness and microaggressions against clients.
These problems are not simply academic, but result in substandard care, inappropriate treatments, and premature termination from treatment. In particular, African Americans are more often given the diagnosis of paranoid schizophrenia than non-Hispanic Whites with similar symptoms (Snowden & Pingitore, 2002). This could be due in part to misinterpretation by clinicians of “healthy cultural paranoia”—a defensive posture taken by African Americans when approaching a new situation that could involve racism or discrimination (Whaley, 2001). This paranoia is not completely unfounded given the reality of discrimination and racial tensions in the United States. Additionally, African Americans are more likely to be admitted as inpatients, even after controlling for severity of illness and demographic variables (Snowden, Hastings, & Alvidrez, 2009).
For Hispanic Americans the research results are mixed. Chui (1996) finds that Hispanics receive a diagnosis of schizophrenia less often than African Americans and non-Hispanic Whites, but they more often receive diagnoses of other mental illnesses. Solomon (1992) reports that more Puerto Ricans are diagnosed as schizophrenic than any other group, including other Hispanics. This could be due to the intersection of race and ethnicity, as many Puerto Ricans are both Black and Hispanic. Furthermore, when minorities are diagnosed with psychotic or affective disorders the conditions are more likely to be considered chronic rather than acute when compared with European Americans with the same diagnoses.
Likewise, assessments of dangerousness and potential for violence are overestimated for African American inpatients, in accordance with violent and criminal stereotypes (Good, 1996; Wood, Garb, Lilienfeld, & Nezworski, 2002). One result of this bias is the overmedication of Black psychiatric patients (Wood et al., 2002). This is compounded by the fact that African Americans, like many other ethnic minorities, metabolize antidepressants and antipsychotic medications more slowly than Whites and may be more sensitive to the medications. This higher sensitivity is manifested in a faster and higher rate of response and more severe side-effects, including delirium, when treated with doses commonly used for White patients (Munoz & Hilgenberg, 2006). Thus, African Americans may exhibit poorer medication compliance, which then may be misinterpreted as resistance to treatment.
Interestingly, Hispanic Americans are less likely to be medicated at all (Hodgkin, Volpe-Vartanian, & Alegria, 2007). Aside from limited health care access among Latino populations (Perez-Escamilla, 2010), another potential explanation could be a lack of adherence to medication throughout the course of mental illness (Hodgkin et al., 2007; Colby, Wang, Chhabra, & Pérez-Escamilla, 2012). In particular, Hodgkin et al. (2007) utilized data from the NLAAS and found that 18.9% of Hispanic Americans who discontinued antidepressant medication decided to do so without consulting a health professional. Researchers noted that proficiency in the English language, older age, being married, having insurance, and consistent visits to see a therapist were related to better antidepressant adherence in this sample.
African Americans are diagnosed less accurately than non-Hispanic Whites when they are suffering from depression and seen in primary care (Borowsky et al., 2000), or when they are seen for psychiatric evaluation in an emergency room (Strakowski et al., 1997). One study found that African Americans were less likely than Whites to receive an antidepressant when their depression was first diagnosed (27% vs. 44%), and among those who did receive antidepressant medications, African Americans were less likely to receive the newer SSRI medications than were the White patients (Melfi, Croghan, & Hanna, 2000).
In terms of substance abuse, 15% of the general population will abuse a substance in their lifetime and 4% will abuse a substance within 12 months (Kessler et al., 2005a; Kessler et al., 2005b). Negative social stereotypes dictate that drug users are largely Black and Hispanic. Most people are surprised to learn that African American youth are significantly less likely to use tobacco, alcohol or drugs than non-Hispanic Whites or Hispanic Americans (Centers for Disease Control, 2000). In fact, African Americans spend 25% less than Whites on alcohol (U.S. Department of Labor, 2002). The National Longitudinal Alcohol Epidemiological Survey (1996) indicated that Whites were more likely to use drugs over the lifetime but Blacks were more dependent than Whites, underscoring differential access to effective treatments (Grant, 1996). Blacks and Whites tend to abuse different drugs (e.g. crack vs. cocaine), and the drugs used by African Americans carry harsher penalties and are more likely to be the targets of law enforcement efforts (e.g., Beckett, Nyrop, & Pfingst, 2006). Thus, institutionalized racism may play a role in drug abuse outcomes and access to treatment.
Conclusions
This chapter represents a charge to mental health professionals to fully consider and subsequently integrate racial, ethnic, and cultural variables into the assessment and treatment of ethnic minority individuals. The importance of such integration undoubtedly has a profound impact on several areas, including but not limited to the following: assessment, expression of psychopathology, diagnostic practices, mental health disparities, treatment outcome studies, continued dearth of ethnic minorities involved in research studies, and a continued paucity of researchers and practitioners of color. Explicit acknowledgment of inherent biases that we all possess and an understanding of the importance of incorporating cultural variables throughout all portions of our work with ethnic minority populations are important first steps to decreasing mental health disparities. Additionally, we continue to underscore the importance of reviewing the empirical literature as it pertains to ethnic minority populations since “all measures are not created equal.” Moreover, there continues to be a disconnect between much of our scientific training with regard to making decisions about assessment measures, how psychopathology is expressed in many ethnic minority individuals, which often deviates from “traditional” expressions, and our subsequent implementation of treatment. Spiritual identity is also essential to many ethnic minority individuals, and incorporating such variables into both the assessment and treatment process is essential. We are additionally emphasizing the importance of respecting (and sometimes incorporating when agreed upon by the client) and seeking assistance from traditional healers or spiritual elders into the treatment process.
Although significant strides have been made in the more recent empirical literature endemic to ethnic minority individuals, we as mental health professionals have to be increasingly cognizant of integrating identified cultural factors throughout all facets of our own work and in training the next generation. Ethnoracial minorities are currently 36.6% of the US population, and 50.4% of all births (U.S. Census Bureau, 2011, 2012), with non-Hispanic Whites projected to be a minority in the United States by 2050 (Nagayama Hall, 2001). Thus, much of the work that we have highlighted is vitally important to our cultural competence in the 21st century.
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Chapter 11
Trauma and Stressor-Related Disorders: Post-traumatic Stress Disorder, Acute Stress, and
Adjustment Disorder
s
Anouk L. Grubaugh
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013) includes a chapter titled “Trauma and Stress-Related Disorders,” which contains post-traumatic stress disorder (PTSD), acute stress disorder (ASD), and the adjustment disorders. Both PTSD and ASD were previously classified under the “Anxiety Disorders” chapter of the DSM-IV, whereas adjustment disorders were classified separately as a residual diagnostic category (APA, 1994). PTSD is characterized as a psychiatric disorder resulting from a life-threatening event and requires a history of exposure to a traumatic event (criterion A) that results in a minimum threshold of symptoms across four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity (criteria B–E). Additional criteria concern duration of symptoms (criterion F), functioning (criterion G), and differential diagnosis due to a substance or other co-occurring condition (criterion H).
For criterion A, an event associated with PTSD must include actual or threatened death, serious injury, or sexual violation resulting from one or more of the following scenarios:
· Directly experiencing the traumatic event.
· Witnessing the traumatic event in person.
· Experiencing the actual or threatened death of a close family member or friend that is either violent or accidental.
· Directly experiencing repeated and extreme exposure to aversive details of the event (i.e., the types of exposure frequently encountered by police officers and first responders).
With regard to criteria B–E, an individual must report symptoms from each of the four symptom clusters. Intrusion symptoms (criterion B) include repetitive, involuntary, and intrusive memories of the event; traumatic nightmares; dissociative reactions (i.e., flashbacks) along a broad continuum; intense prolonged distress after exposure to reminders of the trauma; and heightened physiological reactivity to reminders of the trauma. Avoidance symptoms (criterion C) include avoidance of trauma-related thoughts or feelings; and avoidance of people, places, activities, and so forth that cue distressing thoughts or feelings about the traumatic event. Negative alterations in cognitions and mood symptoms (criterion D) include a persistent and distorted sense of self or the world; blame of self or others; persistent trauma-related emotions such as anger, guilt, shame; feeling estranged or detached from others; marked lack of interest in pre-trauma activities; restricted range of affect; and difficulty or inability remembering important parts of the traumatic event. Finally, alterations in arousal and reactivity symptoms (criterion E) include irritability and aggressiveness, self-destructive or reckless behaviors, sleep difficulties, hypervigilance, marked startle response, concentration difficulties, and sleep disturbance.
For a diagnosis of PTSD, an individual must exhibit at least one symptom from criterion B, one symptom from criterion C, two symptoms from criterion D, and two symptoms from criterion E, and the symptoms endorsed in categories B through E must be present for 1 month or longer (criterion F). The symptoms must also be accompanied by significant distress or impairment in social, occupational, or other important life domains (criterion G), and symptoms cannot be better explained by another medical or psychiatric illness (criterion H).
The DSM-5 includes two additional specifiers or associated features that can be added to a PTSD diagnosis: “with dissociated symptoms” and “with delayed expression.” The dissociated symptoms specifier includes either depersonalization (i.e., experience of being an outside observer to one’s experience or feeling detached from oneself) or derealization (i.e., experience of unreality or distortion) in response to trauma-related cues. The delayed onset specifier includes an onset of symptoms that can occur immediately after the trauma, but that may not meet full criteria for PTSD until at least 6 months after the trauma.
Some notable changes were made to the diagnostic criteria for PTSD from DSM-IV (APA, 1994) to DSM-5. In addition to the inclusion of specifiers for depersonalization and derealization, the DSM-5 provides greater specification regarding what events constitute a traumatic event (i.e., what events constitute a criterion A event); and excludes the need for an individual to have experienced intense fear, helplessness, or horror at the time of the trauma due to its lack of predictive utility. Additionally, the avoidance/numbing symptom cluster found in the DSM-IV is divided into two distinct clusters in the DSM-5: avoidance and negative alterations in cognitions and mood. The second of these clusters retain most of the DSM-IV numbing symptoms while also including a broader range of emotional reactions. Last, criterion E, alterations in arousal and reactivity, retains the majority of DSM-IV arousal symptoms but also includes additional symptoms regarding aggressive or reckless behavior.
A diagnosis of ASD requires an antecedent event (criterion A event) in which the person:
· experienced an event or events that involved a threat of death, actual or threatened serious injury, or actual or threatened physical or sexual violation;
· witnessed an event or events that involved the actual or threatened death, serious injury, or physical or sexual violation of others;
· learned of such harm coming to a close relative or friend;
· experienced repeated or extreme exposure to aversive details of unnatural death, serious injury, or serious assault or sexual violation of others that were not limited to electronic media, television, video games, and so forth.
Individuals must then exhibit a minimum of nine out of 14 symptoms across a broad spectrum of post-traumatic reactions (criterion B). This spectrum includes symptoms related to negative mood, intrusive thoughts, dissociation, avoidance, and anxiety. Aside from a greater emphasis on dissociative symptoms, the other criterion B symptoms for ASD largely mirror the criteria B–E symptoms for PTSD. Additional criteria for ASD concern duration of symptoms (criterion C), functioning (criterion D), and differential diagnosis due to a substance or other co-occurring condition (criterion E).
Changes to the diagnostic criteria of ASD from DSM-IV to DSM-5 include less emphasis on dissociative criteria (i.e., feeling detached from one’s body, emotions, or the world). Rather than being required for a diagnosis, as was the case in the DSM-IV, dissociative symptoms in DSM-5 are viewed as one of several possible post-traumatic reactions that an individual may experience. Comparable to changes to the diagnostic criteria for PTSD, the DSM-5 provides more specification regarding the qualifying traumatic event for ASD; and the criterion requiring a subjective reaction to the trauma (i.e., fear, helplessness, horror) was eliminated.
Adjustment disorders are classified in the DSM-5 as a range of stress response syndromes. This differs from the DSM-IV in which adjustment disorders were part of a residual category for individuals experiencing clinically significant distress that did not fit diagnostic criteria for other psychiatric disorders. Specific DSM-5 criteria for an adjustment disorder include: (a) the development of emotional or behavioral problems in response to an identifiable stressor occurring within 3 months of exposure to the stressor (this feature is considered the core feature of adjustment disorders; (b) symptoms or behaviors are clinically significant and out of proportion to the severity of the stressor once cultural and contextual factors are taken into account. Additionally, the stress response (a) cannot be better accounted for by another disorder and is not an exacerbation of a pre-existing condition; (b) is not indicative of normal bereavement (if this is the precipitating event); and (c) once the stressor is removed, the symptoms do not persist for more than an additional 6 months. Diagnostic specifiers for the adjustment disorders include depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified.
Whereas PTSD and ASD emphasize fear and anxiety responses, adjustment disorders can accommodate a broader range of stress reactions. Second, although there is an explicit potential for ASD to predict subsequent impairment (i.e., to predict the development of PTSD), an adjustment disorder is typically viewed as a discrete disorder that has a fairly immediate onset and is relatively short in duration. A third distinction between PTSD, ASD, and adjustment disorders regards the timing of diagnosis. Adjustment disorders can be diagnosed immediately after the event, ASD can be diagnosed from 2 days up to 1 month after the event, and PTSD can be diagnosed from 1 month to several years after the trauma.
Clinical Features
The clinical expression of PTSD can vary significantly in terms of severity. Although the diagnosis is categorical, there is evidence of a dimensional structure to PTSD (Broman-Fulks et al., 2006; Forbes, Haslam, Williams, & Creamer, 2005). An implication of this dimensional structure is that milder symptoms of PTSD may cause significant distress and impairment. A recent meta-analytic review found that individuals with subthreshold PTSD experienced worse psychological and behavioral impairment than did individuals without PTSD, but less impairment relative to those with full PTSD (Brancu et al., 2016). Several of the studies cited also reported an increased risk of suicidality and hopelessness as well as higher health care utilization among those with subthreshold PTSD relative to those without PTSD.
Suicidality is elevated among individuals with PTSD (Bentley et al., 2016; McKinney et al., 2017), and particular types of trauma, such as childhood abuse, military sexual trauma, and combat, may be more strongly associated with suicidality than others (Kimerling et al., 2016; McLean et al., 2017). Additionally, increased risk of suicidality is uniquely associated with PTSD (McKinney et al., 2017). That is, this association is not solely accounted for by the presence of other psychiatric conditions commonly found with PTSD. Of course, an increased risk of suicidality is present in a number of other psychiatric conditions to a comparable or greater degree than that found in PTSD (Nock, Hwang, Sampson, & Kessler, 2010).
The clinical picture of ASD is similar to that of PTSD. Additionally, a review on the topic found that at least half of trauma survivors with ASD subsequently met criteria for PTSD (Bryant, Friedman, Spiegel, Ursano, & Starin, 2011). A more recent evaluation using DSM-V criteria found that 43% of individuals with ASD developed PTSD at 3 months and 42% of individuals with ASD developed PTSD at 12 months (Bryant et al., 2015). This study also found that DSM-V criteria for ASD were better than DSM-IV criteria for predicting PTSD. These findings suggest that individuals with ASD are, in fact, at higher risk of subsequently developing PTSD, and that DSM-V may yield more predictive validity for PTSD than earlier versions of the DSM.
Due to the conceptualization of adjustment disorders as fairly time-limited, as well as their history as a nebulous catch-all diagnostic category they have not been well studied in the psychiatric literature. The findings that do exist consist largely of non-US samples, focus on children or adolescents, and/or were published in the 1980s and early 1990s. Some commonly agreed-upon emotional signs of adjustment disorder are sadness, hopelessness, lack of enjoyment, crying spells, nervousness, anxiety, worry, trouble sleeping, difficulty concentrating, feeling overwhelmed, and thoughts of suicide. Some behavioral signs of disorders include fighting, reckless behaviors, neglecting important tasks or responsibilities, and avoiding family or friends. Although the presence of an adjustment disorder has been linked to increased suicidal ideation and risk of suicide in a review of the topic (e.g., Appart et al., 2017), they are often considered less severe than other psychiatric disorders. Supporting this view, one study found that adjustment disorders range in severity between no psychiatric disorder and the presence of a mood or anxiety disorder (Fernandez et al., 2012).
Diagnostic Considerations
Comorbidity is common with PTSD. Large, nationally representative samples have found that PTSD is significantly correlated with the majority of mood and anxiety disorders, as well as alcohol use disorders (National Comorbidity Survey Replication [NCS-R]; Kessler, Chiu, Demler, & Walters, 2005; National Comorbidity Survey [NCS]; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Data from the NCS-R found that approximately half of those who met criteria for PTSD also met criteria for at least three additional psychiatric diagnoses (Kessler et al., 1995). Although there is some degree of symptom overlap between PTSD and other psychiatric diagnoses (e.g., sleep and concentration difficulties and diminished interest in activities are common to both depression and PTSD), this overlap does not account for the high rate of comorbidity (Elhai, Grubaugh, Kashdan, & Frueh, 2008). When comorbid with mood disorders, PTSD is more likely to be primary, whereas it is more likely to be secondary when comorbid with anxiety disorders (Kessler et al., 1995). Importantly, PTSD and comorbid diagnoses may change over time within a given individual. A study of trauma survivors found that half of those who reported PTSD only at 3-month follow-up reported depression only at 12-month follow-up; likewise, half of those with depression only at 3-month follow-up reported PTSD only at 12-month follow-up (O’Donnell, Creamer, & Pattison, 2004).
Due to the lack of epidemiological studies specific to ASD or the adjustment disorders, there are few reliable data on the clinical comorbidity associated with these disorders. Given the conceptual overlap between ASD and PTSD, it is likely that individuals with ASD experience high rates of mood, anxiety, and substance disorders relative to the general population, as well as an increased risk of suicidality. As noted elsewhere, adjustment disorders in the DSM-IV served as a residual “catch-all” diagnostic category once other psychiatric conditions were ruled out. As such, they are seldom diagnosed with other psychiatric conditions. With this restriction in mind and the lack of studies using DSM-V criteria, adjustment disorders have most often been linked in adult samples to a comorbid diagnosis of a personality disorder or certain personality profiles and increased suicidality (Appart et al., 2017).
Epidemiology
In the general population, the 12-month and lifetime prevalence rates of PTSD are 3.5% and 6.8%, respectively (Kessler, Burglund, Demler, et al., 2005; Kessler et al., 2005). Point prevalence of PTSD among US combat veterans is estimated to be between 2% and 17%, depending on the characteristics of the sample and the measurement strategies that were used (Richardson, Frueh, & Acierno, 2010). There are different conditional probabilities of developing PTSD by trauma type. For example, combat exposure and physical and sexual abuse are more often associated with PTSD than are other types of trauma. Despite this variability, the symptom expression of PTSD remains fairly consistent regardless of the type of trauma experienced.
Little is known about the prevalence of ASD and the adjustment disorders in the general population. Large-scale epidemiological studies, such as the World Health Organization (WHO) Mental Health Epidemiologic Survey, the Epidemiologic Catchment Area study, and the National Comorbidity Survey Replication, did not report on these disorders. Rates of ASD in community and clinical samples range from 7% to as high as 28%, with a mean rate of 13% (Bryant et al., 2011), and rates of ASD are typically higher among victims of violent versus nonviolent traumas. When subsyndromal cases of ASD are included, estimates of the disorder increase from 10% to 32% with a mean rate of 23% (Bryant et al., 2011).
There are few reliable findings on the prevalence of adjustment disorders. This gap in our knowledge is likely influenced by the poor delineation between adjustment disorders and normal or adaptive stress responses, as well as the use of adjustment disorders as a residual “last resort” diagnostic category in the DSM-IV. One epidemiological study, the European Outcome of Depression International Network, found a 1% prevalence of adjustment disorder with depressed mood (ODIN; Ayuso-Mateos et al., 2001). More circumscribed samples of adults suggest that adjustment disorders are more common in hospital psychiatric consultation settings (12%; Strain et al., 1998; 18.5%; Foster & Oxman, 1994) and among psychiatric inpatient admissions (Koran et al., 2002). A recent meta-analysis found prevalence rates of 15.4% and 19.4% in palliative care and oncology settings, respectively (Mitchell et al., 2011).
Psychological and Biological Assessment
There are a number of diagnostic measures for assessing PTSD. The Clinician-Administered PTSD Scale (CAPS; Weathers, Keane, & Davidson, 2001) is the most common interviewer-based instrument for PTSD and has robust psychometric properties (Weathers et al., 2001). The CAPS was revised for DSM-V and includes a detailed assessment of each traumatic event, a combined frequency and severity rating for each symptom, and overall distress and impairment ratings. Other interview measures include the PTSD Symptom Scale–Interview (PSS-I for DSM-V; Foa et al., 2016), the Structured Clinical Interview for PTSD (SCID; First et al., 2015), and the Anxiety Disorders Interview Schedule for DSM-V (ADIS-V; Brown & Barlow, 2014).
Self-report questionnaires may also be used to assess PTSD. Commonly used measures include the PTSD Checklist for DSM-V (Weathers et al., 2013b), the Posttraumatic Diagnostic Scale for DSM-V (PDS; Foa, 2016), and the Life Events Checklist for DSM-V (LEC-5; Weathers et al., 2013a). A more extensive list of measures used to assess PTSD is available from the National Center for PTSD (
www.ptsd.va.gov
). Not all of these measures have been updated to reflect changes in PTSD criteria from DSM-IV to DSM-V.
Aside from interview and self-report measures of PTSD, several physiological variables have been found to distinguish current PTSD from lifetime PTSD and the absence of PTSD. These include an increased resting heart rate, an increased response to non-trauma-related stressors, and increased heart rate, skin conductance, and diastolic blood pressure in response to trauma cues (Shvil et al., 2013). However, the diagnostic utility of these physiological variables is limited in that they tend to be less accurate than interview-based and self-report assessments in predicting PTSD.
There are few empirically validated diagnostic measures for ASD or adjustment disorders. Measures designed specifically for ASD include the Acute Stress Disorder Interview (ASDI) and the Acute Stress Disorder Scale (ASDS), both developed by the same group of investigators (Bryant, Harvey, Dang, Sackville, & Basten, 1998). The SCID-V contains an optional module for ASD, as well as a section on adjustment disorders that specifies that the diagnosis should not be made if the criteria for any other psychiatric disorders are met (First et al., 2015). With regard to physiological measures, there are some data indicating that individuals who subsequently develop PTSD have higher heart and respiration rates immediately post-trauma as compared with those who do not (Bryant et al., 2011). However, these data are not limited to individuals with ASD, and are likely hampered by the same classification precision of these measures for PTSD.
Etiological Considerations
A number of causal mechanisms have been implicated in the development of PTSD. These include genetic factors, brain structure and neurochemical abnormalities, pre- and post-trauma life events, cognitive appraisals and attentional biases, and sociodemographic variables such as gender.
Behavioral and Molecular Genetics
Increasing data support the role of gene–environment interactions in PTSD (Mehta & Binder 2012). Among Vietnam era veterans, the risk of developing PTSD has been explained by (a) a genetic factor common to alcohol use and PTSD, (b) a genetic factor associated with PTSD but not with alcohol use, and (c) unique environmental effects (Xian et al., 2000). Yet another twin study of Vietnam-era veterans found that the genetic factors that accounted for the relationship between combat exposure and PTSD also accounted for the relationship between combat exposure and alcohol use (McLeod et al., 2001). Genetic factors contributed more to the relationship between combat exposure and PTSD as compared with environmental factors, whereas genetic and environmental factors contributed equally to the relationship between combat exposure and alcohol use. Interestingly, the genetic factors that account for the presence of PTSD may also influence exposure to certain types of traumatic events. Concordance of both interpersonal violence and PTSD is higher among monozygotic twins than among dizygotic twins, whereas other types of trauma (i.e., natural disasters, motor vehicle accidents) are not accounted for by genetic factors (Stein, Jang, Taylor, Vernon, & Livesley, 2002).
In terms of specific genetic markers, the 5-HTTLPR polymorphism has been associated with an increased risk of developing PTSD in specific groups of trauma survivors, including hurricane survivors with a high degree of exposure (Kilpatrick et al., 2007) and individuals reporting a traumatic event in childhood as well as adulthood (Xie et al., 2009). A similar interaction has been reported for variants of polymorphisms in the FK506 binding protein 5 (FKBP5) gene, which is involved in regulating the intracellular effects of cortisol. Individuals with these variants, who reported severe child abuse, were found to be at increased risk for developing PTSD after experiencing a traumatic event in adulthood (Binder et al., 2008; Xie et al., 2009). This gene was under-expressed among survivors of the September 11, 2001 attacks on the World Trade Center who developed PTSD compared with those who did not (Yehuda et al., 2009). There is evidence for candidate genes in other systems (e.g., the dopamine system), but findings have been limited or inconsistent (Broekman, Olff, & Boer, 2007; Koenen, 2007; Nugent, Amstadter, & Koenen, 2008). Genetic research on the trauma and stress-related disorders of the DSM-5 are limited to PTSD.
Neuroanatomy and Neurobiology
Several brain structures have been implicated in PTSD, including the amygdala, the medial prefrontal cortex, and the hippocampus. First, PTSD is associated with increased activation in the amygdala in response to trauma-related stimuli (Francati, Vermetten, & Bremner, 2007). This increased activity likely represents the neural substrates of exaggerated fear acquisition and expression and may explain the salience of trauma memories in PTSD (Rauch, Shin, & Phelps, 2006). Importantly, hyperactivity in the amygdala is not unique to PTSD; increased activity in response to disorder-related stimuli has also been noted in specific phobia and social anxiety disorder (Etkin & Wagner, 2007; Shin & Liberzon, 2010). Second, PTSD is associated with deficient functioning in the medial prefrontal cortex (Francati et al., 2007; Shin & Liberzon, 2010). This deficiency is thought to underlie inadequate top-down modulation of the amygdala (Rauch et al., 2006). Moreover, the medial prefrontal cortex is thought to regulate processes that are important for habituation and extinction of fear responses, including emotional appraisal (Liberzon & Sripada, 2008). Third, PTSD is associated with abnormalities in the hippocampus. These abnormalities may underlie difficulties contextualizing memories (e.g., recognizing that certain contexts are safe; Liberzon & Spirada, 2008; Rauch et al., 2006). A meta-analysis concluded that increased PTSD severity is associated with decreased volume of the hippocampus, as well as decreased volume in the amygdala and the anterior cingulate, a structure in the medial prefrontal cortex (Karl et al., 2006).
Decreased hippocampal volume likely represents a risk factor for developing PTSD, as opposed to a neurobiological effect of trauma (McNally, 2003). Consistent with this, hippocampal volume does not change over time following trauma exposure (Bonne et al., 2001). Moreover, a study of veteran twin pairs discordant for combat exposure and PTSD found that PTSD severity among affected twins was negatively correlated with not only their own hippocampal volume but also that of their nonexposed twin (Gilbertson et al., 2002).
The neurochemical underpinnings of PTSD likely involve catecholamines (epinephrine, norepinephrine, and dopamine) and cortisol, a hormone involved in the neuroendocrine response to stress, as well as a variety of other neurotransmitters (Yehuda, 2006). PTSD may also be characterized by disturbance of the hypothalamic–pituitary–adrenal axis, arising primarily from hypersensitivity of glucocorticoid (i.e., cortisol) receptors (Yehuda et al., 2009). This may represent a risk factor, although the research findings are not yet clearly integrated into a cohesive model.
There are few data specifically reporting on neurobiological models of ASD or adjustment disorders. When viewed as a stress reaction conceptually related to PTSD, ASD in particular may also involve a dysregulation of the neurotransmitter and neuroendocrine systems implicated in PTSD. In addition, ASD may quite possibly involve deficits in certain brain regions such as the hippocampus, which are implicated as a risk factor for PTSD.
Learning, Modeling, and Life Events
Clearly, traumatic life events contribute to PTSD. Less clear is whether trauma exposure and PTSD share a dose–response relationship in which frequency and/or intensity of trauma correspond with symptom severity. Rates of PTSD vary based on the type of traumatic event, with assaultive violence and sexual assault being associated with the highest rates (Breslau et al., 1998; Norris, 1992). Furthermore, rates of PTSD among veterans roughly correspond to degree of combat exposure (Dohrenwend et al., 2006). However, PTSD severity has not been found to correspond to severity of exposure in other trauma samples such as motor vehicle accident survivors and political prisoners (Başoğlu et al., 1994; Schnyder, Moergeli, Klaghofer, & Buddeberg, 2001). Importantly, a dose–response relationship between trauma exposure and PTSD may be nonlinear. That is, after a certain degree of trauma exposure, symptom exacerbation may reach a plateau (McNally, 2003).
Post-traumatic stress disorder may also be related to degree of trauma exposure prior to the traumatic event. Exposure to childhood physical or sexual abuse is associated with an increased risk of future trauma exposure, as well as the development of PTSD in response to those subsequent traumas (Koenen, Moffitt, Poulton, Martin, & Caspi, 2007). In addition to previous childhood abuse or neglect, meta-analyses on the topic have identified other pre-trauma risk factors for PTSD, such as level of prior psychological adjustment and/or the presence of a previous personal or family history of psychiatric illness. Post-trauma risk factors include a lack of social support and additional life stressors (Brewin, Andrews, & Valentine, 2000; Keane, Marshall, & Taft, 2006; Ozer, Best, Lipsey, & Weiss, 2008).
Few studies have examined risk factors specifically in relation to the development of ASD or adjustment disorders. However, given the conceptual overlap between PTSD and ASD, they likely share similar pre- and post-trauma risk factors. Supporting this line of reasoning, one study found that individuals with a previous history of trauma exposure or PTSD and those with more psychiatric dysfunction were at greater risk for developing ASD when experiencing a new trauma (Barton, Blanchard, & Hickling, 1996).
Cognitive Influences
Cognitive influences of PTSD include maladaptive beliefs that one holds about the meaning of the traumatic event that is experienced (e.g., self-blame, guilt). Consistent with this view, cognitive processing therapy (CPT) emphasizes the importance of identifying and revising maladaptive beliefs about the trauma and promoting a more balanced integration of the traumatic event (Resick & Schnicke, 1993). Other possible cognitive mechanisms of PTSD include attentional or memory related biases toward threat-related stimuli or trauma-related material, which may specifically reflect a cognitive vulnerability to developing PTSD (Brewin & Homes, 2003; Fani et al., 2012; Weber, 2008). PTSD may also be influenced by perceived seriousness of threat, which in turn may be influenced by cognitive variables such as poor contextualization of autobiographical memory (Ehlers & Clark, 2000). Although not specific to ASD, a number of studies have found that maladaptive or negative appraisals and beliefs predict the subsequent development of PTSD (Bryant, Salmon, Sinclair, & Davidson, 2007; Mayou, Bryant, & Ehlers, 2001).
Sex and Racial-Ethnic Considerations
Epidemiological surveys suggest that women are more likely to report sexual assault or child molestation and men are more likely to report physical assault, combat exposure, or being threatened or attacked with a weapon (Norris, 1992). Prevalence studies of PTSD further indicate that women are more likely to develop PTSD relative to men (at a 2:1 ratio) given exposure to a traumatic event (Norris et al., 1992). That is, women have a higher conditional risk of developing PTSD relative to men. Traumas associated with ASD are similar to those for PTSD. However, systematic efforts are needed to confirm whether gender differences in rates of ASD are comparable to those associated with PTSD.
Findings regarding the interplay among trauma exposure, PTSD, and race/ethnicity are often mixed (Pole, Gone, & Kulkarni, 2008). Overall, however, most studies have found comparable rates of PTSD between African Americans and Caucasians. The few studies that have found significant racial/ethnic differences report higher base rates of PTSD among African Americans relative to Caucasians that largely disappear once severity of trauma exposure is controlled for. The most consistent findings regarding PTSD and race/ethnicity pertain to Hispanics. Relative to non-Hispanic Caucasians, Hispanics often have higher rates of PTSD in both community and clinical samples (Pole et al., 2008). Cultural context may influence some aspects of PTSD, but the disorder generally presents as a coherent group of symptoms across cultures. Parallel efforts to study the relationship between race/ethnicity and both ASD and adjustment disorders are lacking.
Course, Prognosis, and Treatment
According to the DSM-5, symptoms consistent with a diagnosis of PTSD may begin immediately following or long after a traumatic event, and there is sufficient evidence that PTSD can persist for several years after the index trauma. The diagnostic specifier “with delayed expression” allows for a diagnosis of PTSD when all of the criteria for the disorder are not met for 6 months or longer after the traumatic event. A review on the occurrence of delayed-onset PTSD revealed an average prevalence of 5.6% (Utzon-Frank et al., 2014). The proportion of delayed-onset PTSD cases relative to all PTSD cases was 24.5%, with significant variation in rates across studies. It was further noted that delayed-onset PTSD was almost always preceded by subthreshold PTSD symptoms. Data show that delayed-onset PTSD in the absence of prior symptoms is exceedingly rare (Andrews, Brewin, Philpott, & Stewart, 2007; Frueh, Grubaugh, Yeager, & Magruder, 2009). These and other findings suggest that delayed-onset PTSD is likely due to an exacerbation of prior symptoms over time.
Post-traumatic stress disorder symptoms can persist over time. Findings from the National Vietnam Veterans Longitudinal Study found that 4.5% of male veterans met criteria for DSM-V PTSD 40 years after the Vietnam War (Marmar et al., 2015). In a national sample of Vietnam-era male twins, 3.65% of theatre veterans retained their PTSD diagnosis 20 years later (Magruder et al., 2016). Studies using civilian samples likewise suggest that PTSD can be a chronic condition but report much shorter time frames from the baseline to follow-up.
Parallel with its theoretical underpinnings, clinical practice guidelines generally recommend cognitive behavioral interventions as the most effective treatment approach for PTSD (DVA, 2010; Foa, Keane, & Friedman, 2009; IOM, 2007; NICE, 2005). Treatments that fall under this umbrella typically include elements of psychoeducation, stress reduction, exposure to trauma-related cues and memories, and cognitive restructuring, with the latter two components being considered the “active ingredients” for PTSD symptom reduction.
Although there are a number of interventions that emphasize exposure and/or cognitive restructuring, the empirical data weigh heavily in support of two specific manualized treatments for adults with PTSD: prolonged exposure (PE—an exposure-based intervention; Foa, Hembree, & Rothbaum, 2007) and CPT (predominantly a cognitive restructuring intervention that includes elements of exposure; Resick & Schnicke, 1993). The focus in PE is on habituation to graded fear exposures, whereas the focus in CPT is on modification of maladaptive trauma-related beliefs (e.g., denial or self-blame). However, CPT often includes exposure exercises, and PE often includes elements of cognitive restructuring. Adding cognitive restructuring to PE does not appear to increase its efficacy (Foa et al., 2005), nor does adding writing exposure exercises to CPT (Resick et al., 2008), indicating that the therapies are efficacious in both their combined and component forms.
Reviews on the topic suggest the average patient receiving PE or CPT fares better than 86–90% of patients who are assigned to a control group (i.e., do not receive what is considered an active treatment) (Bradley, Greene, Russ, Dutra, & Westen, 2005; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). Despite the overall efficacy of PTSD interventions, 18–35% of individuals who complete treatment retain the diagnosis at follow-up, with civilians showing dramatically greater improvement than military veterans (Bradley et al., 2005). Disability incentives to remain ill have been posited as one possible reason why veterans evidence less clinical improvement than civilians (Frueh, Grubaugh, Elhai, & Buckley, 2007), as have other characteristics unique to veteran populations (e.g., nature of combat trauma). Additionally, treatment dropout rates hover around 30% across clinical populations (Cloitre, 2009). Recently, multicomponent interventions combining exposure therapy and other cognitive-behavioral interventions (e.g., behavioral activation, anger management, social skills) have been demonstrated to be effective in treating the range of symptoms associated with the PTSD syndrome (e.g., Acierno et al., 2016; Beidel, Frueh, Uhde, Wong, & Mentrikoski, 2011). Multicomponent interventions have also been shown to have special promise when delivered in an intensive outpatient program format (Beidel, Frueh, Neer, & Lejuez, 2017).
Reflecting neurobiological models of the disorder, pharmacological treatments for PTSD act primarily on the neurotransmitters associated with fear and anxiety, which include serotonin, norepinephrine, GABA, and dopamine. Selective serotonin reuptake inhibitors (SSRIs) are generally considered the pharmacological treatment of choice for PTSD (DVA, 2010; Hoskins et al., 2015; Stein, Ipser, & McAnda, 2009), and this class of drugs include the only two medications that are currently FDA-approved for the treatment of PTSD—sertraline (Zoloft) and paroxetine (Paxil). Although there is some support for the efficacy of psychotropic medications for the treatment of PTSD, not all practice guidelines support their use. For example, after a review of 37 PTSD pharmacotherapy trials, the Institute of Medicine determined that there was insufficient evidence in support of any psychotropic medications for PTSD including SSRIs (IOM, 2007). A more recent review found that SSRIs were superior to placebo in reducing PTSD symptoms but the effect size was small (Hoskins et al., 2015). Additionally, psychotropic medications do not typically alleviate all the symptoms associated with this disorder and it is generally recommended that patients take medications in conjunction with a psychotherapy specifically developed to treat PTSD, particularly with more complex symptom presentations.
Brief cognitive behavioral interventions immediately post-trauma have yielded promising results in terms of preventing the subsequent development of PTSD among those with ASD (Bryant, Moulds, Nixon, & Basten, 2003; Echeburua, deCorral, Sarasua, & Zubizarreta, 1996; Gidron et al., 2001). These interventions generally consist of education about symptoms, relaxation training, exposure exercises, and cognitive therapy. In contrast, psychological debriefing interventions, which were sometimes used in the aftermath of traumatic events like natural disasters, have failed to demonstrate sufficient efficacy and are generally contraindicated with more severe traumas or post-traumatic reactions (Forneris et al., 2013; North & Pfefferbaum, 2013).
Due to the acute nature of most adjustment disorders, they often do not require treatment, or require limited treatment. Additionally, however, the high degree of variability in the symptom expression of adjustment disorders has likely complicated the development of standardized treatment approaches. Consistent with this, systematic investigations on the efficacy of specific interventions for adjustment disorders are limited to two randomized controlled trials, one targeting adjustment disorder with depressed mood secondary to myocardial infarction (Gonzales-Jaimes & Turnbull-Plaza, 2003) and another targeting adjustment disorder resulting in occupational dysfunction (van der Klink, Blonk, Schene, & van Dijk, 2003). Both of these interventions were tailored for a specific target population and anticipated deficits, with the first demonstrating efficacy of the intervention in terms of symptom reduction and the latter in terms of decreasing absenteeism but not symptom reduction. Pharmacotherapy trials for the treatment of adjustment disorders are likewise few in number and have not established the superiority of antidepressants versus placebo for symptom reduction (Casey, 2009; Casey et al., 2013). Less systematic efforts and clinical wisdom would suggest that psychosocial treatments for adjustment disorders should be relatively brief in duration, and focus on decreasing or removing the stressor as well as improving the patient’s adaptation and coping skills.
Case Studies
Post-Traumatic Stress Disorder
Paul is a 26-year-old African American Iraq War veteran who presented to his local VA primary care clinic due to feelings of anxiety. Paul served two tours of duty in Iraq and witnessed multiple roadside bombings in which members of his unit were injured and killed. His final tour ended 2 years ago. He reports symptoms that began shortly after the first roadside bombing he witnessed while overseas, and an increase in the severity and frequency of these symptoms since his return to the US. He experiences frequent nightmares and intrusive memories about Iraq, including nightmares and unwanted thoughts related to a bombing in which he witnessed the death of two of his comrades with whom he was particularly close. Paul questions in his mind why he lived while his comrades died and feels certain that he should have been able to prevent what happened. He avoids internal and external reminders of the event, which include thinking about the bombings and other graphic scenes from his service, as well as driving. Last, he is experiencing marked irritability, anger, and hypervigilance, especially while driving. Paul often catches himself gripping the steering wheel of his car, anticipating an improvised explosive device. Because of his symptoms, Paul’s relationships have suffered, most notably his relationship with his girlfriend of several years, who has made a number of comments to him about him having changed since coming back from Iraq and not being the same “easygoing” guy she met. Paul is enrolled in college under the GI Bill and is having difficulty studying due to problems concentrating and a persistent lack of sleep. He fears he may have to withdraw from the semester.
Paul’s experiences in Iraq are consistent with the definition of a traumatic event, and his symptoms reflect chronic PTSD with acute onset.
Adjustment Disorder
Susan is a 42-year-old Caucasian woman who presented to her primary care physician for her annual appointment. During the course of the appointment, Susan admits to her physician that she has been struggling emotionally since the end of her marriage (2 months prior) and the loss of her job (9 months prior). After both of these events, but to a much greater extent since her son moved out of the home, Susan describes feeling a mixture of depression and sadness about her failed marriage and lack of new job prospects, as well as general feelings of anxiety and fear about her future. She reports feeling at a loss as to how to manage her time and feels overwhelming sadness at being 45 and alone, with few friends or family to rely on. She acknowledges calling in sick from work a few times a month for the past few months and then ruminating about the potential consequences of having not gone in to work. She reports watching television several hours a day followed by periods of anxious and somewhat obsessive housecleaning. She also reports having crying spells “over just about anything” and is tearful while discussing her symptoms during her primary care appointment.
Susan’s clinical presentation is consistent with a diagnosis of adjustment disorder with mixed anxiety and depressed mood.
Summary
Post-traumatic stress disorder, ASD, and adjustment disorders are classified in the DSM-5 as trauma- and stress-related disorders that were precipitated by a stressful or traumatic event. The value of classifying these disorders together will enable clinicians to better differentiate normal and mild stress reactions from more severe and pathological stress reactions. It also more clearly highlights the temporal and symptom requirement distinctions between PTSD, ASD, and adjustment disorders. Whereas PTSD and ASD emphasize fear and anxiety responses, adjustment disorder symptoms can accommodate a broader range of stress reactions. Second, although there is an explicit potential for ASD to predict subsequent impairment (i.e., to predict PTSD), an adjustment disorder is typically viewed as a discrete disorder that has a fairly immediate and time-limited symptom duration. A third distinction between PTSD, ASD, and adjustment disorders regards the timing of diagnosis. Adjustment disorders can be diagnosed immediately after the event, ASD can be diagnosed from 2 days up to 1 month after the event, and PTSD can be diagnosed from 1 month to several years after the trauma.
In conclusion, based on being linked to a clear precipitating stressful or traumatic event, PTSD, ASD, and adjustment disorders are viewed as stress reactions along a continuum that are differentiated by the severity of the initial stressor, an anxiety-focused or broader set of symptoms in reaction to the event, and the onset and duration of the symptoms. PTSD and ASD share many of the same symptoms, with ASD being limited in duration to 1 month, and in some but not all cases predicting the subsequent development of PTSD. The relationship among adjustment disorders, PTSD, and ASD is poorly understood as there has been little systematic study on the topic. The placement of adjustment disorders in the same chapter as PTSD and ASD in the DSM-5 will likely prompt a better understanding of the unique and overlapping features of this disorder in relation to PTSD and ASD. Future studies will likely shed light on the similarities and differences between these three disorders with regard to prevalence, diagnosis, clinical presentation, correlates, and treatment.
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Chapter 12
Somatic Symptom and Related Disorders
Gordon J. G. Asmundson and Daniel M. LeBouthillier
Description of the Disorders
The somatic symptom and related disorders were introduced in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013) and replaced the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; APA, 2000) somatoform disorders. Changes were made in an effort to eliminate overlap and clarify boundaries between diagnosable disorders and to recognize that people meeting diagnostic criteria for one of these disorders may or may not have an identifiable medical condition; however, as noted later, there is continuing debate as to the validity of the changes made. The somatic symptom and related disorders include somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder.
Specific Disorders
The common feature of the somatic symptom and related disorders is prominent somatic sensations (e.g., dyspnea, pain) or changes (e.g., subcutaneous lumps, rash)—called “symptoms” in DSM-5 terminology—that are associated with significant emotional distress and functional impairment and often interpreted by the person as being symptomatic of some disease process or physical anomaly. Bodily sensations and changes are a ubiquitous experience, and they typically remit without medical attention; however, about 25% of the population seeks medical attention when these sensations and changes persist (Kroenke, 2003). Up to 30% of those seeking medical attention will exhibit clinically significant distress about having an unidentified disease when there is no medical explanation for presenting “symptoms” (Fink, Sørensen, Engberg, Holm, & Munk-Jørgensen, 1999); yet many remain distressed despite identifiable medical explanation (APA, 2013; Taylor & Asmundson, 2004). This distress is associated with substantial impairment of personal, social, and professional functioning as well as considerable costs to health care (Hessel, Geyer, Hinz, & Brahier, 2005), even after controlling for medical and psychiatric comorbidity (Barsky, Orav, & Bates, 2005).
Despite the prevalence and cost of distressing somatic sensations and changes, as well as a substantive increase in empirical attention during the past decade, understanding of their presentation remains limited. Likewise, although there are some data on the validity, reliability, and clinical utility of the diagnoses of somatic symptom disorder and illness anxiety disorder (Bailer et al., 2016; Dimsdale et al., 2013; van Dessel, van der Wouden, Dekker, & van der Horst, 2016), there have been few studies on the diagnostic category as a whole. In the sections that follow, we provide an overview of the general clinical profile, diagnostic considerations, and epidemiology of the somatic symptom and related disorders. Assessment, etiological considerations, and course and prognosis are also considered. In each of these latter sections, we touch on issues germane to the collective category as well as its specific disorders. In the case study, we focus more specifically on an illustration of uncomplicated somatic symptom disorder. There are currently few data on epidemiology, etiology, course, prognosis, assessment, or treatment of the somatic symptom and related disorders; therefore, much of the data presented below are borrowed from pre-DSM-5 knowledge of related conditions and disorders.
Clinical Picture
The clinical profile for each somatic symptom and related disorder is unique, although each disorder is predicated on the prominence of somatic sensations or changes associated with distress and impairment. A brief overview of the clinical profile of each somatic symptom disorder is provided, along with reference to DSM-5 diagnostic criteria.
Somatic Symptom Disorder
Somatic symptom disorder is the cornerstone diagnosis of the somatic symptom and related disorders category. The main feature of somatic symptom disorder is the presence of one or more somatic symptoms or features that cause distress and impairment in daily living (criterion A). The concern ranges from highly specific (e.g., “This pain in my gut is so bad. I must have stomach cancer”) to vague and diffuse (e.g., “My whole body is aching. What could it be? Maybe it’s ALS”). Individuals with somatic symptom disorder exhibit excessive thoughts, feelings, or behaviors related to their somatic symptoms (criterion B). An individual meets criterion B if he or she: (a) exhibits disproportionate thoughts about the seriousness of their symptoms, (b) experiences persistently high levels of anxiety regarding their symptoms or about their health, or (c) devotes an excessive amount of time to their health (e.g., seeking reassurance from health professionals, doing research about their somatic sensations or changes, perusing body parts to find potential lumps). Excessive somatic concerns must persist for at least 6 months (criterion C), although somatic symptoms do not need to be present for this entire period. Individuals with somatic symptom disorder may often resist the idea that they are suffering from a mental health disorder and may come to rely on reassurance-seeking (e.g., deriving comfort from assurances by significant others that everything is okay) and checking behaviors (e.g., palpating subcutaneous lumps, searching for information about disease in medical textbooks and on the Internet) to placate concerns about having a serious disease. Although these behaviors can be effective in providing short-term relief, they perpetuate the condition in the long term (Taylor & Asmundson, 2004).
There are several diagnostic specifiers that can accompany somatic symptom disorder. When somatic complaints revolve largely around pain, the “with predominant pain” specifier can be applied. This specifier replaces the pain disorder diagnosis from DSM-IV. The persistent specifier applies in cases where severe symptoms and impairment last for longer than 6 months. Finally, severity can be specified as mild, moderate, or severe when an individual meets one, two, or three of the criterion B symptoms, respectively. For example, a moderate severity specifier is assigned to an individual who reports debilitating anxiety due to bodily symptoms and who checks their body for hours a day to ensure no new blemishes have appeared.
Illness Anxiety Disorder
Illness anxiety disorder involves preoccupation with having or acquiring a serious illness (criterion A). For example, an individual may fear contracting HIV or having recently contracted the virus. Illness anxiety disorder differs from somatic symptom disorder in that somatic symptoms are not present or are only minor (criterion B). If minor somatic symptoms are present (e.g., light pain, minor bruising), the individual’s distress is clearly out of proportion to the actual threat and focuses more on the meaning of the symptoms (e.g., consequences of having diabetes) rather than on the somatic symptoms themselves. Individuals with illness anxiety disorder experience a great deal of distress rooted in their disease-related preoccupations and are easily alarmed about health-related matters (criterion C). To illustrate, an individual with illness anxiety disorder may be excessively distressed when learning that a colleague or family member has been diagnosed with cancer. Individuals with illness anxiety disorder participate in excessive behaviors aimed at reducing their anxiety (criterion D), often bodily checking (e.g., looking for lesions that could be signs of an infection), reassurance-seeking (e.g., repeatedly seeking medical testing), health-related research (e.g., reading about HIV on the Internet), and avoidance (e.g., avoiding hospitals as these could house harmful germs). These behaviors may placate concerns in the short term but, ultimately, serve to reinforce disease-related preoccupation (Taylor & Asmundson, 2004). A diagnosis of illness anxiety disorder is contingent on illness anxiety lasting at least 6 months (criterion E), although the focus of the anxiety may change during this time (e.g., from HIV to syphilis). Finally, the symptoms of illness anxiety disorder must not be better explained by another diagnosis (criterion F), such as somatic symptom disorder, panic disorder, or obsessive-compulsive disorder. There are two contrasting specifiers that can accompany illness anxiety disorder. The care-seeking type specifier is applied when individuals frequently seek medical care, whereas the care-avoidant type specifier is applied when individuals rarely use medical care.
Conversion Disorder (Functional Neurological Symptom Disorder)
Conversion disorder involves the manifestation of altered voluntary motor or sensory functioning (criterion A). Motor symptoms can include paralysis, paresthesia, tremors, convulsions, and abnormal movements or posture. Sensory symptoms can include blindness, altered or reduced hearing, unusual or inconsistent skin sensations, and altered speech patterns. The hallmark of conversion disorder is a lack of correspondence between signs and symptoms and medical understanding of the possible neurological condition (criterion B). For example, an individual may display symptoms very consistent with epileptic seizures, but lack electrical activity in the brain consistent with epilepsy. Such an inconsistency is needed for a diagnosis. A lack of neurological evidence for reported or observed symptoms is not sufficient (e.g., trembling without any apparent brain damage). Symptoms of conversion disorder must not be better explained by another mental health or medical disorder (criterion C) and the symptoms must cause clinically significant distress or impairment or warrant medical evaluation (criterion D).
People with conversion disorder are often unaware of psychological factors associated with their condition, and many report an inability to control their symptoms. Although not a criterion for diagnosis, lack of worry or concern about symptoms (i.e., la belle indifference) is mentioned in the DSM-5 list of associated features; however, the extant literature fails to support the use of la belle indifference as a means of discriminating between conversion disorder and symptoms of organic pathology (Stone, Smyth, Carson, Warlow, & Sharpe, 2006).
Observed signs and symptoms of conversion disorder often appear to represent patient beliefs about how neurological deficits should present, rather than how neurological diseases actually function (Hurwitz, 2004). Onset typically follows a period of distress, such as that stemming from trauma (McFarlane, Atchison, Rafalowicz, & Papay, 1994; Roelofs, Keijsers, Hoogduin, Naring, & Moene, 2002; Van der Kolk et al., 1996) or physical injury (Stone et al., 2009). There are several specifiers that can accompany conversion disorder, including with psychological stressor or without psychological stressor and acute episode (i.e., when symptoms present for less than 6 months) or persistent (i.e., when symptoms present for more than 6 months).
Psychological Factors Affecting Other Medical Conditions
A diagnosis of psychological factors affecting other medical conditions is given to individuals who suffer from a medical condition (criterion A) that is adversely affected by psychological or behavioral factors (criterion B). The effects on the medical condition can increase the odds of suffering, disability, or death. Psychological or behavioral factors can be deemed as detrimental if meeting one of the following conditions: (a) the psychological or behavioral factors preceded the development or worsening of the medical condition, or delayed recovery from the condition (e.g., repeatedly exacerbating an injury following discharge from hospital); (b) the factors interfere with treatment; (c) the factors are well established health risks; or (d) the factors influence medical pathology, thereby exacerbating symptoms or requiring medical attention. Psychological or behavioral factors can include distress, maladaptive interpersonal patterns, and poor treatment adherence. The psychological or behavioral factors must not be subsumed within another mental disorder (criterion C); thus, worsening of a medical condition due to panic disorder or due to substance abuse would not meet criteria for psychological factors affecting other medical conditions. The degree of influence of psychological factors on a medical condition can be specified as mild (increases medical risk), moderate (aggravates medical condition), severe (results in hospitalization or emergency attention), or extreme (life-threatening risk).
Factitious Disorder
Factitious disorder imposed on self is a condition wherein an individual acts as if they have physical or psychological signs of an illness by producing, feigning, or exaggerating symptoms (criterion A). The individual must present as ill or impaired (criterion B) and a diagnosis is contingent on identifying that the individual is actively misrepresenting their condition. Moreover, the deceptive behavior must occur without any obvious external rewards (criterion C), such as monetary compensation or reduced responsibilities. A diagnosis of factitious disorder can be assigned to individuals who have a medical condition, but, in such cases, the deceptive behavior is intended to make the person appear even more ill. The deceptive behavior cannot be better explained by another disorder, such as schizophrenia or delusional disorder (criterion D). Individuals with factitious disorder may produce or exaggerate symptoms by consuming drugs (e.g., insulin, hallucinogens), injecting themselves with noxious substances (e.g., bacteria), contaminating blood and urine samples, or reporting symptoms that have never occurred (e.g., seizures). A specifier of recurrent episodes is applied in cases where the individual has exhibited deceptive behavior more than once.
A separate diagnosis, referred to as factitious disorder imposed on another, can also be assigned. The criteria for this diagnosis are the same as factitious disorder, but a person other than the victim conducts the deceptive behavior. For example, a parent may tamper with the urine sample of his or her child to misrepresent the child’s health status. In this case, the parent would be assigned the diagnosis, not the child.
Other Specified Somatic Symptom and Related Disorder and Unspecified Somatic Symptom and Related Disorder
Other specified somatic symptom and related disorder applies to individuals who present with distressing or impairing symptoms that are similar to one of the somatic symptom and related disorders but that do not fully satisfy the criteria for a diagnosis. The DSM-5 presents four specific disorders that can be used with the other specified disorder diagnosis. These include brief somatic symptom disorder, which can be assigned when an individual meets diagnostic criteria for somatic symptom disorder, but for less than 6 months; brief illness anxiety disorder, which can be assigned when symptoms of illness anxiety disorder last for less than 6 months; illness anxiety disorder without excessive health-related behaviors, which can be assigned when an individual meets all criteria for illness anxiety disorder except criterion D; and, pseudocyesis, which can be assigned in individuals with a false belief of being pregnant that is associated with objective and reported signs of pregnancy (e.g., morning sickness, breast tenderness). A diagnosis of unspecified somatic symptom and related disorder is applied when an individual presents with distressing or impairing symptoms that are similar to a somatic symptom and related disorder, but that do not meet the diagnostic criteria for any of the somatic symptom and related disorders.
Diagnostic Considerations (Including Dual Diagnosis)
To qualify for a DSM-IV-TR somatoform disorder diagnosis, somatic signs and symptoms were required to be medically unexplained (i.e., they could not be explained by organic pathology or physical deficit). Suggesting that diagnoses based on the absence of medically explained symptoms promoted stigma, the Somatic Symptom Workgroup noted that the reliability of establishing that somatic symptoms are not due to a general medical condition is low (Dimsdale et al., 2013; also see Sykes, 2006). As a consequence, DSM-5 somatic symptom disorder is defined on the basis of positive symptoms (i.e., distressing somatic symptoms that present along with “observable” cognitions, emotions, and behaviors in response to the somatic symptoms). It is, therefore, possible for people presenting with and without a diagnosable general medical condition to satisfy diagnostic criteria for the disorder. Medically unexplained symptoms only remain relevant to conversion disorder and other specified somatic symptom and related disorder (i.e., pseudocyesis), where it is possible to demonstrate inconsistency between presenting symptoms and medical pathology.
In arriving at a diagnosis of one of the somatic symptom and related disorders it is important to consider that there are multiple sources of distressing somatic sensation and changes. First, a number of mental health disorders are characterized by somatic symptoms (e.g., depression, panic disorder, post-traumatic stress disorder) and may either account for or accompany the somatic symptoms. In the former case, a somatic symptom and related disorder diagnosis would not be warranted, whereas in the latter case, a dual diagnosis would be warranted. Likewise, given that distressing somatic symptoms often occur in response to a general medical condition, such as cancer or multiple sclerosis, considerable care is warranted in establishing whether the response is psychopathological in nature. Some critics of the DSM-5 are concerned that diagnostic thresholds have been loosened to the point where clinicians will be challenged in distinguishing normal from psychopathological responses in those with distressing somatic symptoms stemming from a medical condition, resulting in overdiagnosis of somatic symptom disorders (Frances, 2013). There are also concerns about the validity of the new diagnostic criteria, particularly somatic symptom disorder (Rief & Martin, 2014). It is also important to recognize that many benign physical factors can give rise to somatic signs and symptoms. Consider, for example, physical deconditioning. People concerned by somatic sensations often avoid physical exertion, including aerobic and anaerobic exercise, for fear that it will have harmful consequences (Taylor & Asmundson, 2004). As a result, they become physically deconditioned. Physical deconditioning is associated with postural hypotension, muscle atrophy, and exertion-related breathlessness and fatigue, all of which can promote further inactivity and reinforce beliefs that one is ill.
According to the APA (2013), somatic symptom disorder encapsulates approximately 75% of individuals who previously met diagnostic criteria for hypochondriasis, and likely represents the most prevalent of the somatic symptom and related disorders. Emerging evidence on validity of the new classification of somatic symptom and related disorders suggests that only approximately half of individuals who meet DSM-IV-TR criteria for a somatoform disorder also meet criteria for a DSM-5 diagnosis of somatic symptom disorder (van Dessel, van der Wouden, Dekker, & van der Horst, 2016), although other research has found similar or slightly greater rates of diagnosis for somatic symptom disorder compared with DSM-IV-TR somatoform disorder (Voigt et al., 2012). Nonetheless, those who meet the DSM-5 criteria appear to have greater symptom severity and lower physical functioning, supporting the clinical utility of the diagnosis (van Dessel et al., 2016). There is criticism regarding splitting of new diagnoses; indeed, research on hypochondriasis suggests that about three-quarters of individuals diagnosed meet DSM-5 criteria for somatic symptom disorder and one-quarter for illness anxiety disorder, but that the two groups have few differences in terms of attitudes, behaviors, and physical symptoms (Bailer et al., 2016). Further research is required to determine whether the modifications made in the DSM-5 facilitate accuracy of diagnoses relative to that attainable with the DSM-IV-TR somatoform disorders. The importance of diagnosis cannot be overstated, as any diagnosis carries significant implications for individuals receiving the diagnosis and their related experiences (e.g., stigmatization, interpretation of symptoms, nature of treatment, response to treatment). As Kirmayer and Looper (2007) have noted, diagnosis is a form of intervention and, as such, is a crucial element in shaping treatment and outcome.
Epidemiology
Somatic symptom and related disorders are often associated with true or perceived organic pathology; consequently, this class of disorders is a challenge to diagnose and to study from an epidemiological standpoint due to difficulties in thoroughly assessing the mind and body. Given the substantial changes in diagnostic criteria between the DSM-III and DSM-5, providing precise epidemiological prevalence rates for somatic symptom and related disorders is extremely challenging. Indeed, the somatoform disorders were not included in the large-scale national comorbidity surveys based on DSM-III-R (Kessler, 1994) and DSM-IV-TR criteria (Kessler, Chiu, Demler, Merikangas, & Walters, 2005), nor were they examined in the World Health Organization World Mental Health Surveys initiative (Kessler & Üstün, 2008), which further limits inferences regarding the somatic symptom and related disorders. Moreover, epidemiological researchers have often paired somatoform disorders with other disorders (e.g., anxiety disorders; Bland, Orn, & Newman, 1988) or have excluded specific disorders from analyses due to low or high base rates or differences in classification methodologies (Leiknes, Finset, Moum, & Sandanger, 2008). Consequently, the prevalence of somatic symptom and related disorders as a class of disorders remains understudied and our knowledge at this time can only be extrapolated from earlier research on the somatoform disorders.
As noted earlier, the somatic symptom and related disorders are substantially different from the somatoform disorders described in DSM-IV-TR; however, some of the broader epidemiological findings likely still hold true. For example, presentation of somatic concerns that do not meet diagnostic criteria for a somatoform disorder or medical condition account for approximately half of all physician visits (Nimnuan, Hotopf, & Wessely, 2001), suggesting that subsyndromal somatic symptom presentations are highly prevalent and costly (Barsky et al., 2005; Kirmayer & Robbins, 1991). Somatic symptom and related disorders are likely more common in women (Wittchen & Jacobi, 2005), with perhaps the exception of somatic symptom disorder, which appears to have similar prevalence in both genders based on the rates of hypochondriasis (Asmundson, Taylor, Sevgur, & Cox, 2001; Bleichhardt & Hiller, 2007). People with a somatic symptom and related disorder are also very likely to frequently experience co-occurring mood disorders (Leiknes et al., 2008), anxiety disorders (Lowe et al., 2008), personality disorders (Bornstein & Gold, 2008; Sakai, Nestoriuc, Nolido, & Barsky, 2010), as well as other somatic symptom and related disorders (Leiknes et al., 2008).
Somatic symptom disorder has a prevalence of approximately 5–7% in the general population (APA, 2013), which is consistent with the 12-month prevalence rate of 4.5% for hypochondriasis (Faravelli et al., 1997). Research on hypochondriasis suggests that somatic symptom disorder is likely more common in primary care settings. Reported prevalence rates of hypochondriasis in primary care settings have varied considerably based on methodology. Studies using diagnostic interviews have reported a point prevalence of 3% (Escobar et al., 1998) and a 12-month prevalence of 0.8% (Gureje, Üstün, & Simon, 1997), whereas a study using cutoff scores from self-report measures followed by interviews suggests a 12-month prevalence of 8.5% (Noyes et al., 1993). The inclusion of the with predominant pain specifier to somatic symptom disorder, which subsumes a portion of the DSM-IV pain disorder diagnosis, may increase the prevalence of somatic symptom disorder beyond the prevalence of hypochondriasis.
The prevalence of illness anxiety disorder is relatively unknown, but can be estimated based on other phenomena. The 1- to 2-year prevalence of health anxiety and disease conviction (i.e., the belief that one has a disease) in community-based samples ranges from 1.3% to 10% (APA, 2013). A strong fear of contracting a disease, which is relatively similar to illness anxiety disorder, has a point prevalence of approximately 3– 4% (Agras, Sylvester, & Oliveau, 1969; Malis, Hartz, Doebbeling, & Noyes, 2002). Together these findings suggest that illness anxiety disorder is relatively common. The point and 12-month prevalence rates of conversion disorder in the general population are less than 0.1% (Akagi & House, 2001). Point prevalence rates in neurology and primary care settings have been reported as 1% (Smith, Clarke, Handrinos, Dunsis, & McKenzie, 2000) and 0.2% (de Waal, Arnold, Eekhof, & van Hemert, 2004), respectively. Despite low prevalence of conversion disorder, medically unexplained neurological symptoms are present in approximately 11– 35% of neurology patients (Carson et al., 2000; Snijders, de Leeuw, Klumpers, Kappelle, & van Gijn, 2004), suggesting that subsyndromal conversion may be more common than almost all neurological diseases. The prevalence of other somatic symptom and related disorders are unknown, partially because they are new diagnoses (e.g., psychological factors affecting other medical conditions) and are very difficult to study (e.g., factitious disorder, unspecified somatic symptom and related disorder).
Psychological and Biological Assessment
Individuals with somatic symptom and related disorders will typically present in primary care and other medical (nonpsychiatric) clinics rather than in mental health settings; indeed, they may often refuse a mental health referral because of a belief that their condition is purely organic. Cooperation between medical and mental health professionals aids the referral process and, due to the complexity of the factors involved (e.g., possibility of co-occurring organic pathology), is typically necessary in making an accurate diagnosis. Throughout the course of assessing a person with a possible somatic symptom and related disorder, the mental health professional must seek to establish and maintain rapport and should clearly relay an understanding that, although a disease process may or may not be present, the symptoms are real and not feigned or “in the head” (Taylor & Asmundson, 2004). The general goals of assessment for the somatic symptom and related disorders are to rule out organic pathology-based, substance-based, or other psychopathology-based explanations of presenting signs and symptoms, to determine the type and severity of signs and symptoms, and to facilitate appropriate treatment planning.
Ruling out organic pathology is no longer requisite to diagnosis of somatic symptom and related disorders, as it was in the DSM-IV-TR somatoform disorders. This aspect of the diagnostic process was considered problematic for two primary reasons. First, it relied heavily on the exclusion of general medical conditions, and 100% certainty was rarely, if ever, possible (Taylor & Asmundson, 2004; Woolfolk & Allen, 2007). Second, diagnosis is not usually based on the absence of something but, rather, according to the presence of positive features of a condition (Dimsdale et al., 2013). Gathering a detailed history of somatic complaints, past and current medical conditions, and medical professionals consulted is a crucial part of a comprehensive diagnostic process and may provide insight regarding the nature of the presenting condition. A consult with the family physician may be necessary to determine the need for further medical assessments; however, caution is warranted, because further assessments may reinforce maladaptive coping (e.g., reassurance-seeking) while also increasing the costs and potential risks associated with medical care.
Structured clinical interviews have proven to be the gold standard in the diagnosis of mental disorders, and will likely remain so for the somatic symptom and related disorders. Broad structured interviews that include sections on numerous mental disorders are the most commonly utilized. The Structured Clinical Interview for the DSM-IV (First, Spitzer, Gibbon, & Williams, 1996) and the Composite International Diagnostic Interview (CIDI; World Health Organization, 1990) based on the International Statistical Classification of Diseases, 10th edition, criteria (ICD-10; World Health Organization, 2007) were both used widely and demonstrated efficacy and reliability in diagnosing somatoform disorders. Other useful structured interviews for diagnosing somatoform disorders included the Somatoform Disorders Schedule (World Health Organization, 1994), the Schedules for Clinical Assessment in Neuropsychiatry (Wing et al., 1990), and the Diagnostic Interview Schedule (Robins, Helzer, Croughan, & Ratcliff, 1981). The majority of these structured interviews have not been updated for DSM-5 somatic symptom and related disorders, with the exception of the Structured Clinical Interview for DSM-5 (First, Williams, Karg, & Spitzer, 2015), which queries somatic symptom disorder and illness anxiety disorder. Additionally, the Health Preoccupation Diagnostic Interview (Axelsson, Andersson, Ljótsson, Wallhed Finn, & Hedman, 2016) is a newly developed instrument for the diagnosis of DSM-5 somatic symptom disorder and illness anxiety disorder that has preliminary evidence for its reliability.
Structured clinical interviews can be supplemented with diarized monitoring of catastrophic thinking and maladaptive coping behaviors as well as information gleaned from standardized self-report measures. Self-report measures are efficient and effective screening tools that can provide invaluable information for case conceptualization and regular monitoring of treatment progress. The Screening for Somatoform Symptoms (Rief, Hiller, & Heuser, 1997), the Symptom Checklist-90, Revised (Derogatis, 1975), or the Patient Health Questionnaire-15 (Kroenke, Spitzer, & Williams, 2002) have been used to assess a broad range of somatic symptoms. More specific information can be derived from a wide array of self-report measures that have been developed to assess the severity of specific somatic symptoms. It is beyond the scope of this chapter to provide a comprehensive list of these measures; examples include the Health Attitude Survey (Noyes, Langbehn, Happel, Sieren, & Muller, 1999), for use in assessing attitudes and perceptions associated with multiple somatic symptoms; the Health Anxiety Questionnaire (Lucock & Morley, 1996), for use in assessing reassurance-seeking behavior and the extent to which symptoms interfere with a person’s life; the Whiteley Index (Pilowsky, 1967), for use in assessing cognitions associated with health anxiety; and the Short Health Anxiety Inventory (Salkovskis, Rimes, Warwick, & Clark, 2002), to assess health anxiety in both medical and nonmedical populations. Instruments developed in relation to the DSM-5 classification include the Somatic Symptom Scale–8 (Gierk et al., 2014; an abbreviated version of the Patient Health Questionnaire-15 developed for DSM-5 somatic symptom disorder field trials), as well as the Somatic Symptom Disorder-B Criteria Scale (Toussaint et al., 2015, 2017). Medical service utilization and visual analogue scales pertaining to distressing thoughts and maladaptive coping behaviors can also be used to assess emotional and functional impact and to monitor treatment progress. Finally, measures of mood and anxiety can be useful in case conceptualization and monitoring and might include the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996), the Beck Anxiety Inventory (Beck & Steer, 1993), and the Anxiety Sensitivity Index-3 (Taylor et al., 2007).
Etiological Considerations
Behavioral Genetics and Molecular Genetics
Heritability of somatoform disorders has been suggested by findings from behavioral (e.g., Kendler et al., 2011; Torgersen, 1986) and molecular (e.g., Hennings, Zill, & Rief, 2009) genetics studies. Somatic symptom concordance rates between monozygotic twins are higher than between dizygotic twins, even when controlling for co-occurring psychiatric symptoms (Lembo, Zaman, Krueger, Tomenson, & Creed, 2009). Although mood and somatoform disorders share common genetic factors (e.g., deregulation of serotonergic pathways), there are numerous genetic features unique to somatoform disorders (e.g., immunological deregulation, hypothalamic–pituitary–adrenal [HPA] axis responses; Rief, Hennings, Riemer, & Euteneuer, 2010). The role of specific genetic markers in the development of somatic symptoms remains unclear; however, research in this area is ongoing, and genetic factors are now being considered within the context of psychological models of various somatoform disorders (e.g., Taylor, Jang, Stein, & Asmundson, 2008; Veale, 2004). Whether these findings generalize to the somatic symptom and related disorders remains to be determined.
Neuroanatomy and Neurobiology
Neurological research on the DSM-5 somatic symptom and related disorders remains in its infancy; but, research using DSM-IV-TR criteria has demonstrated neurological correlates for conversion disorder (e.g., Vuilleumier, 2005), hypochondriasis (e.g., Atmaca, Sec, Yildirim, Kayali, & Korkmaz, 2010), and other related disorders (e.g., somatization disorder; Hakala, Vahlberg, Niemi, & Karlsson, 2006; pain disorder and fibromyalgia, Wood, Glabus, Simpson, & Patterson, 2009). The HPA axis has been a focus of research in this area. A recent longitudinal study reported preliminary evidence that cortisol deregulation in the HPA axis may predate the development of somatic symptoms in some people (Tak & Rosmalen, 2010). The HPA axis controls glandular and hormonal responses to stress and, when stressors (e.g., chronic pain, anxiety) have a chronic course, may lead to hypocortisolism (i.e., adrenal insufficiency), which induces greater stress and enhances experiences of pain and fatigue (Fries, Hesse, Hellhammer, & Hellhammer, 2005). Increases in these experiences typically exacerbate somatic symptoms or lead to behaviors that exacerbate or maintain them (Taylor & Asmundson, 2004). The second somatosensory area (SII) of the cerebral cortex, which is involved in the analysis and evaluation of complex patterns of somesthetic input (e.g., perception of pain, sensations from visceral structures, gastric sensations), has also been implicated as a source of the somatic perturbation associated with the somatoform disorders (Miller, 1984); however, despite its appeal as a neural structure underlying this class of disorders, people presenting with concerns about somatic symptoms do not typically show abnormalities in sensory acuity.
Learning, Modeling, and Life Events
Adverse life events (e.g., childhood physical and sexual abuse, neglect) have been associated with increased physician visits during adulthood (Fiddler, Jackson, Kapur, Wells, & Creed, 2004), health anxiety (Reiser, McMillan, Wright, & Asmundson, 2013), hypochondriasis (Barsky, Wool, Barnett, & Cleary, 1994), and unexplained somatic symptoms (Tak, Kingma, van Ockenburg, Ormel, & Rosmalen, 2015). Unfavorable socioeconomic conditions during development may also be associated with unexplained somatic symptoms in adulthood, likely because socioeconomic status may engender a series of social and material difficulties (Jonsson, San Sebastian, Strömsten, Hammarström, & Gustafsson, 2016); however, it is noteworthy that increased prevalence of abuse and other stressful life events are characteristic of people with a variety of psychiatric conditions (e.g., panic disorder; Taylor, 2000), not just those presenting with concerns regarding somatic symptoms. Early childhood experiences of illness and perceptions of significant illness in others are associated with the experience of medically unexplained symptoms in adulthood (Hotopf, Wilson-Jones, Mayou, Wadsworth, & Wessely, 2000). Likewise, parents who fear disease, who are preoccupied with their bodies, and who overreact to minor ailments experienced by their children are more likely to have children with the same tendencies, both during childhood and adulthood (Craig, Boardman, Mills, Daly-Jones, & Drake, 1993; Hotopf, Mayou, Wadsworth, & Wessely, 1999; Marshall, Jones, Ramchandani, Stein, & Bass, 2007). That being said, a recent twin study suggests that environmental factors not shared by twins (e.g., an ailment in one of the twins), rather than shared environmental factors (e.g., parental style), seem most important in the development of DSM-IV-TR-defined hypochondriasis (Taylor & Asmundson, 2012).
Cognitive Influences
Greater focus on somatic sensations is associated with greater experiences of those sensations (Brown, 2004; Ursin, 2005). When attention is directed to the body, the intensity of perceived sensations increases (Mechanic, 1983; Pennebaker, 1980). People with somatoform disorders have been shown to spend a considerable amount of time focusing on their bodies, thereby increasing their chances of noticing somatic sensations and changes. They also tend to believe that somatic sensations and changes are indicative of disease or are otherwise harmful in some way (Barsky, 1992; Taylor & Asmundson, 2004; Vervoort, Goubert, Eccleston, Bijttebier, & Crombez, 2006). These beliefs increase the attention directed to somatic sensations and changes and, in turn, increase associated distress. It is likely that similar cognitive influences will be identified in the various somatic symptom and related disorders diagnoses.
Sex and Racial-Ethnic Considerations
As noted in the “Epidemiology” section, the somatoform disorders were more prevalent in women than in men, perhaps with the exception of hypochondriasis. There are several possible explanations for this difference. Because women are more likely to seek medical services (Corney, 1990; Kessler et al., 2008), they may be more prone to diagnostic biases wherein physicians consider somatic symptoms presented by a woman as more likely to be psychological than organic in nature (e.g., Martin, Gordon, & Lounsbury, 1998). Women also tend to experience higher rates of psychopathology (Kessler et al., 2008). Shared etiological or maintenance factors between mental disorders may make it more likely that women are at a higher risk of developing a somatic symptom and related disorder. There is evidence that women tend to focus more on their bodies (Beebe, 1995) and are more fearful of some of their bodily sensations (Stewart, Taylor, & Baker, 1997), further increasing their risk for developing somatic symptom and related disorders. Other putative sex differences have been proposed (e.g., differential experiences of abuse; HPA axis dysregulation) but warrant further empirical scrutiny in the context of their role in somatic symptom and related disorders etiology.
Somatic sensations and changes are common in all cultural groups; however, presentation varies widely depending on sociocultural norms (Kirmayer & Young, 1998). Cultural factors, such as socially transmitted values, beliefs, and expectations, can influence how a person interprets somatic sensations and changes, and whether treatment-seeking is initiated. Some cultures appear to be more distressed by gastrointestinal sensations (e.g., excessive concerns about constipation in the UK), whereas others are more distressed by cardiopulmonary (e.g., excessive concerns about low blood pressure in Germany) and immunologically based (e.g., excessive concerns about viruses and their effects in the USA and Canada) symptoms (Escobar, Allen, Hoyos Nervi, & Gara, 2001). Whether one seeks care for somatic concerns also appears to vary as a function of culture, with those of Chinese, African American, Puerto Rican, and other Latin American descent presenting with more medically unexplained somatic symptoms than those from other groups (Escobar et al., 2001). Whether concern over somatic sensations and changes are excessive needs to be judged in the context of the individual’s cultural background.
Course and Prognosis (Including Issues of Treatment)
As a diagnostic category, somatic symptom and related disorders share somatic features and concerns as a prominent aspect of clinical presentation. That said, each disorder does not necessarily share a similar course and prognosis. Like the somatoform disorders, course and prognosis may vary considerably, because the disorders are heterogeneous in presentation and involve substantial comorbidity with mood and anxiety disorders, personality disorders, and, in some cases, general medical conditions. Certain prognostic indicators have been shown to be common across somatoform disorders; for example, comorbidity with other psychiatric disorders contributes to a more chronic and persistent course (e.g., Rief, Hiller, Geissner, & Fichter, 1995). More somatic symptoms, sensitization to bodily sensations and pain, as well as presence of a medical condition all contribute to greater severity and chronic course (APA, 2013). The presence of fewer somatic symptoms, few or no comorbid conditions, identifiable stressors at the time of onset, high intellectual functioning, as well as sound social support networks are typically associated with good prognosis. Also indicative of good prognosis is the development of a strong therapeutic alliance between the patient and care provider, wherein the patient believes that the care provider views the patient’s presenting signs and symptoms as legitimate, albeit possibly not due to an organic pathology or physical defect (Taylor & Asmundson, 2004).
Little research on psychological interventions for somatic symptom disorders currently exists. A recent randomized controlled trial found large improvements in individuals with somatic symptom disorder or illness anxiety disorder engaged in Internet cognitive-behavioral therapy (CBT), unguided Internet CBT, and unguided bibliotherapy compared with a waitlist (Hedman, Axelsson, Andersson, Lekander. & Ljotsson, 2016). CBT has also demonstrated efficacy across the DSM-IV-TR somatoform disorders. The treatment is superior to standard medical care in reducing health-related anxiety (Barsky & Ahern, 2004) and improving somatic complaints/somatization (Allen, Woolfolk, Escobar, Gara, & Hamer, 2006; Speckens, van Hemert, Bolk, Rooijmans, & Hengeveld, 1996). These findings are echoed by a recent meta-analysis of CBT trials for hypochondriasis and health anxiety (Olatunji, Kauffman, Meltzer, Davis, Smits, & Powers, 2014) as well as more recent health anxiety treatment trials (Weck, Neng, Schwind, & Hofling, 2015). Psychiatric consultation letters to primary-care physicians describing somatization and providing recommendations for primary care have also been shown to significantly improve physical functioning and reduce the cost of medical care (Rost, Kashner, & Smith, 1994). Finally, a stepped care approach, including distinguishing between acutely and nonacutely serious complaints, assessing and treating psychiatric comorbidities, and developing a multimodal approach to managing symptoms, could be an effective way forward in addressing somatic symptom disorders in primary care (Hubley, Uebelacker, & Eaton, 2014; Korenke, 2003).
Case Study
Case Identification
The basic features of this case are undisguised; however, in line with Clifft’s (1986) guidelines, identifying information has been altered or omitted to protect confidentiality and privacy.
Jacob is a 37-year-old White male who has been married for 10 years and has a 5-year-old daughter and a 6-month-old son. He currently resides with his wife and children in an upper-middle-class suburban neighborhood. His family is financially secure, and he is not involved in any legal proceedings. Jacob is employed full time as an electrical engineer for a large company, a job he has held for the past 6 years. He enjoys a variety of sports, walking the family dog, and spending time with his family. Until recently, he was active as a competitive triathlete. His job requires that he travel periodically, with absences from home and his family for up to 1 month at a time. He reports that job demands increase in the months prior to extended travel and that his next lengthy trip is fast approaching in 10 weeks.
Presenting Complaints
Jacob was referred by his family physician for assessment and, if appropriate, treatment of increasing anxiety over his physical well-being which was negatively impacting on his work (e.g., spending excessive amounts of time searching medical information on the Internet instead of working) as well as leisure and family functioning (e.g., withdrawing from physical activity and shared leisure activities). These concerns started 9 months ago, when his father died of heart complications associated with amyloidosis, a disease wherein amyloid proteins build up in specific organs and, over time, disrupt organ function and eventually lead to failure of the affected organs. There is a rare form—hereditary amyloidosis—that is most frequently passed from father to son and for which there are no preventive measures other than not having children. There is no cure for amyloidosis, and the effects do not become apparent until later in life (i.e., over the age of 50 years). Beginning shortly after his father’s death, Jacob became increasingly aware of and concerned by somatic sensations in his body—heart palpitations and racing, upper body aches and pain, dizziness, and blurred vision—all of which were similar to those initially experienced by his father. He feared that he may also have amyloidosis and might die from it. His fears were exacerbated upon the birth of his son, with specific concerns that he had passed on the condition and that his son would eventually succumb as well.
History
Jacob had no prior history of mental health problems or treatment and, aside from chickenpox and tonsillitis as a child, had been physically healthy throughout his life. The report from his physician indicated that, despite numerous visits regarding various somatic complaints over recent months, there was no evidence of an organic basis for Jacob’s concerns. The physician report also indicated that Jacob was physically healthy and that he and his son had a pending appointment for genetic testing to rule out the genetic profile for hereditary amyloidosis. Jacob reported having a loving and supportive relationship with his wife, although she was becoming increasingly concerned by his condition and, at times, annoyed at his growing reluctance to actively play with their children. Until recently, he was exercising five or six times per week and had competed in numerous triathlons; however, because of growing concerns about his health, he had significantly cut down his frequency of training and was not competing in order to “avoid physical exertion” for fear that his heart would “explode.” In place of training, he was spending hours checking the Internet for medical information.
Assessment (Related To DSM-5 Criteria)
Jacob was assessed using the Structured Clinical Interview for the DSM-5 and a battery of self-report questionnaires, including (a) the Beck Depression Inventory-II, a measure of depression over the past 2 weeks (Beck et al., 1996), (b) the Beck Anxiety Inventory, a measure of general anxiety over the past week (Beck & Steer, 1993), (c) the Anxiety Sensitivity Index-3 (Taylor et al., 2007), a measure of the fear of arousal-related bodily sensations, and (d) the Whiteley Index (Pilowsky, 1967), a measure of the core features of health anxiety, including disease fear, disease conviction, and bodily preoccupation. The structured interview and self-report measures provided detailed data regarding general features of Jacob’s distress, as well as specific features of his health-related concerns.
Jacob met the DSM-5 diagnostic criteria for somatic symptom disorder. He presented with several specific concerns, including daily worry that somatic changes and sensations (e.g., heart palpitations and racing, upper body aches and pain, dizziness, blurred vision) were signs of physical disease as well as increasing inability to focus on work-related tasks and to be involved in family activities (somatic symptom disorder criterion A). He also presented with considerable worry and anxiety about his personal health and the future-oriented health and well-being of his 6-month-old son, and reported spending hours on the Internet checking medical information (somatic symptom disorder criterion B). His concerns had, as noted previously, begun around the time of his father’s death 9 months prior and had persisted since then (somatic symptom disorder criterion C).
Given that the effects of amyloidosis are typically not evident until later in life, and that Jacob was in his mid-30s, it was deemed unlikely that amyloid deposits were responsible for the bodily sensations he was experiencing; however, since Jacob (and his son) had not yet completed genetic testing and did not know whether they had the genetic profile for hereditary amyloidosis at the time of assessment, we remained cautious in our opinion as to whether his thoughts about the seriousness of symptoms were disproportionate. At the time of assessment, Jacob’s score on the Whiteley Index was moderate overall (score = 8; possible range 0–14), characterized by significant disease fear (score = 3; possible range 0–4) and bodily preoccupation (score = 3; possible range 0–3) but little disease conviction (score = 0; possible range 0–3), the latter of which is indicative of good prognosis with treatment (Taylor & Asmundson, 2004). The moderately high levels of health anxiety combined with excessive checking behavior, in our opinion, were sufficient to warrant a moderate severity specifier.
Jacob did not meet diagnostic criteria for other diagnosis. Scores on the Beck Depression Inventory (score = 13; possible range 0–63) and Beck Anxiety Inventory (score = 26; possible range 0–63) suggested a mildly depressed mood and moderate general anxiety, respectively. The absence of comorbid diagnoses, along with depression and general anxiety in the mild to moderate range, are also indicative of good prognosis with treatment (Taylor & Asmundson, 2004). His score on the Anxiety Sensitivity Index-3 (score = 33; possible range 0–72) indicated strong beliefs that arousal-related bodily sensations have harmful consequences, which, when considered in the context of his significant disease fear and bodily preoccupation, suggest that attention-focusing exercises (e.g., Furer, Walker, & Stein, 2007; Wells, 1997) and interoceptive exposure (Taylor & Asmundson, 2004) may prove to be particularly beneficial additions to treatment.
Summary
Conditions characterized by significant concern over somatic signs and symptoms, often presenting as medically unexplainable, are associated with significant emotional distress, cognitions characterized by catastrophic thinking, maladaptive coping behaviors typically manifest as excessive checking and reassurance-seeking, limitations in social and occupational functioning, and excessive use of health care resources. These conditions are represented by the disorders subsumed under the DSM-5 somatic symptom and related disorders. While it is generally agreed that changes to the former DSM conceptualizations of the somatoform disorders were warranted, it remains to be determined whether the changes set forth in the DSM-5 somatic symptom and related disorders will promote more accurate diagnosis of people concerned and functionally disabled by somatic sensations and changes and, if so, whether this will direct appropriate treatment resources to optimize outcomes. It also remains unclear if, or how, the changes to classification will facilitate efforts to identify underlying mechanisms. The burden on the health care system and the personal distress associated with somatic symptoms highlight the need for appropriate reconceptualization of disorders characterized by somatic symptom presentation; however, some investigators have suggested that there was insufficient empirical evidence to warrant change, that important evidence may have been overlooked, and that the changes in the DSM-5 may have been premature (Taylor, 2009; Sirri & Fava, 2013; Starcevic, 2013) or lacking in precision and clarity (Rief & Martin, 2014), and that the new changes will increase, rather than decrease, diagnostic misclassification (Frances, 2013). Answers to these questions await the accumulation of empirical evidence based on the DSM-5 diagnostic criteria. Efforts such as the EURONET-SOMA initiative (Weigel et al., 2017), which is bringing leading European experts in the field together to work on research agendas, diagnostic issues, and treatment, hold promise in providing answers to the many questions that remain.
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