358 CHAPTER 8
Social Factors
Social factors that can contribute to SD include signifi cant social stressors, the mod-
eling and reinforcement of illness behavior, and cultural infl uences on symptoms.
Let’s examine these social factors.Social Stress In many cases, somatoform disorders, including SD, develop after
the death of a loved one or after another signifi cant social stressor (Hiller, Rief, &
Fichter, 2002). This is what happened to Anna O. after her father died. Somatic
symptoms serve as a coping strategy, leading the person to focus attention away
from the stressor and onto a bodily sensation.Social Learning Observational learning can explain the fi nding that people with SD
are more likely than those without the disorder to have had an ill parent (Bass &
Murphy, 1995; Craig et al., 1993). In these cases, an ill parent may have inadver-
tently modeled illness behavior.
Moreover, operant conditioning can also be at work, when people provide rein-
forcement for an individual’s illness behavior: During the patient’s childhood, fam-
ily members may have unintentionally reinforced illness behavior by paying extra
attention to the child or buying special treats for the child when he or she was ill
(Craig, 1978; Craig et al., 2004; Holder-Perkins & Wise, 2001). Similarly, adults
with SD may be reinforced for their symptoms by the attention of medical person-
nel, family, friends, or coworkers (Maldonado & Spiegel, 2001).Cultural Infl uences on Symptoms In many cultures, including that of the United States,
somatic symptoms may be regarded as an acceptable way to express helplessness, such
as by those who experienced abuse during childhood (Walling et al., 1994). The use
of somatic symptoms to express helplessness may explain the bodily symptoms of
Anna O. and other upper-middle class women of the Victorian era, whose lives were
severely restricted by societal conventions. However, although symptoms of SD occur
around the globe, the nature of the symptoms differs across cultures. For instance,
symptoms of burning hands or feet are more common in Africa and South Asia than
in Europe or North America (American Psychiatric Association, 2000).
In addition, culture influences the prevalence of SD: Although Hispanics
in general are not more likely than others to develop the disorder, Puerto Ricans
are ten times more likely to do so than the general U.S. population (Canino et al.,
1992; Escobar, 1987; Shrout et al., 1992). Moreover, economic status infl uences
prevalence. In contrast to Vienna during Anna O.’s lifetime, people from lower
SES groups today are more likely to develop the disorder than those from higher SES
groups (Wool & Barsky, 1994). One possible explanation is that those in lower
SES groups may feel more helpless.FEEDBACK LOOPS IN ACTION: Somatization Disorder
It is common for people with SD to have had a disease, illness, accident, or other
form of trauma prior to developing the disorder. In fact, people with this disorder
are more likely to report a history of childhood abuse than are other medical patients
(Brown, Schrag, & Trimble, 2005). In individuals who are genetically predisposed
to SD (neurological factor), the bodily sensations caused by an illness or accident
are interpreted as signaling a catastrophic illness (psychological factor). In turn, this
misinterpretation may cause the person to change his or her behavior in a way that
ultimately becomes dysfunctional, restricting activities and straining relationships.
Such misinterpretations may initially grow out of modeling. For example,
consider that children whose parents have chronic pain are more likely to report
abdominal pain themselves and to use more pain relievers than a comparison group
of children (Jamison & Walker, 1992). These children’s experiences with their ill
parent (social factor) may infl uence their body via their brains (perhaps they have
more stomach acid because they are more anxious and stressed; neurological factor),
their attention to and attributions for bodily sensations (psychological factors),
and their reporting of pain (social factor).P SNP SNP SN