Monthly Archives: August 2010

Comparing Factitious Disorders with Malingering


The manifestations of factitious disorder are limited only by human motivation and creativity.  To illustrate this position I would guide the reader to a case study conducted in which a 19 year old female presented to an otolaryngology clinic complaining of bleeding from the mouth, nose, ears, and eyes.  Ultimately Yanik, San, and Alatas (2004) determined that she was smearing her menstrual blood on her face to produce the effect.  Why would someone do such a thing?  Before we can begin to differentiate between factitious disorders and clinical presentations, it is important that we understand the intent of patients of factitious disorder (FD).

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In factitious disorder (FD), patients either intentionally produce or feign signs of medical or psychological disorders, or they misrepresent their histories. The motivation to assume the patient role, rather than to obtain an external reward, distinguishes FD from malingering.  Malingering and FD both differ from somatoform disorders (e.g., somatization disorder, hypochondriasis, persistent somatoform pain disorder) and dissociative/conversion disorders in that the former are marked by active dissimulation, whereas the latter are prompted by unconscious conflicts and symptoms that are not intentionally produced. (Ehrlich, Pfeiffer, Salbach, Lenz, & Lehmkuhl, 2008, p. 392)

The clinical assessment of someone suspected of suffering from a factitious disorder (like most disorders) begins with a careful medical history and comprehensive mental status examination.  Our first consideration is to eliminate investigate the possibilities that the illness is not feigned, but is in fact real.  Typically, the FD case is built through a process of exclusion of actual physical or mental illness, as well as confirmation of intent to assume the “sick role” (thereby differentiating it from malingering).  We as clinicians should carefully document inconsistencies; including inconsistencies among the patient’s account of his or her symptoms (over time), inconsistencies between what we empirically observe and self-reports, and inconsistencies between what is self-reported and what represent typical signs and symptoms of the feigned illness.  (Malone & Lange, 2007)

Possible warning signs of factitious disorders include:

1)      Dramatic but inconsistent medical history

2)      Unclear symptoms that are not controllable and that become more severe or change once treatment has begun

3)      Predictable relapses following improvement in the condition

4)      Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness

5)      Presence of many surgical scars

6)      Appearance of new or additional symptoms following negative test results

7)      Presence of symptoms only when the patient is with others or being observed

8)      Willingness or eagerness to have medical tests, operations, or other procedures

9)      History of seeking treatment at many hospitals, clinics, and doctors offices, possibly even in different cities

10)  Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior doctors (WebMD, n.d.)

Malingering is similar to FD, except that there is an existence of an external reward.  Personal gain is always the motivation; examples might include active duty military personnel seeking medical discharge, or a person attempting to get paid (short-term or long-term) for a nonexistent disability.

Once a legitimate medical condition is eliminated as a possible cause, we are left to attempt to distinguish intent of the client.  Patterns of speech can also be used to detect a potential malingerer.  “Malingerers often sound rehearsed” and, when “led away from these prepared scripts with specific questions,” they tend to “make over-generalized and vague statements.”  When most people lie, they tend to make more negative statements, while using fewer contractions in their speech (e.g., “I do not” instead of the more conversational “I don’t”).  (Malone & Lange, 2007)  The Stroop test has also been found to be effective for detection of malingering of cognitive deficit.  (Osimani, Alon, Berger, & Abarbanel, 1997)

In any event, once the malingering attempt is identified, it must be confronted.  “Approaching the deception as a maladaptive attempt on the patient’s part to resolve a problem or conflict, and drawing analogies to other clinical situations involving more primitive defenses, allows us to use our familiar clinical skills of diagnosis and treatment to resolve our own and the patient’s conflicts in what is often an uncomfortable encounter for both.”  (Malone & Lange, 2007, expression SUMMARY)  Although this will likely be one of the most uncomfortable conversations we can have as clinicians, it can be professionally dealt with and subsequently resolved.

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References

Ehrlich, S., Pfeiffer, E., Salbach, H., Lenz, K., & Lehmkuhl, U. (2008, Sep/Oct). Factitious disorder in children and adolescents: A retrospective study. Psychosomatics, 49(5), 392-399. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1557976921&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Harrison, A. G. (2009, Nov). Clinical assessment of malingering and deception, 3rd edition. Canadian Psychology, 50(4), 294-296. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2003029091&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Malone, R. D., & Lange, C. L. (2007, Spring). A clinical approach to the malingering patient. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35(1), 13-22. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1256972241&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Osimani, A., Alon, A., Berger, A., & Abarbanel, J. M. (1997, Jun). Use of the Stroop phenomenon as a diagnostic tool for malingering. Journal of Neurology, Neurosurgery and Psychiatry, 62(6), 617-622. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=62&did=13146114&SrchMode=1&sid=2&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272133836&clientId=4683

WebMD. (n.d.). Factitious disorders. Retrieved April 24, 2010, from http://www.webmd.com/mental-health/factitious-disorders?page=2

Yanik, M., San, I., & Alatas, N. (2004). A case of factitious disorder involving menstrual blood smeared on the face. International Journal of Psychiatry in Medicine, 34(1), 97-102. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=4&did=692035021&SrchMode=2&sid=3&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272135912&clientId=4683

Nature, nurture, and the effect of theory on personal development


The adoption of one or more developmental theories could have significant implications on implementation of real world therapy practices. Our theoretical worldview has the potential to bias our views of developmental change and the antecedents that drive that change. Will the therapist sitting across from you attribute your current situation to biological antecedents? Is nature responsible for (insert any psychological condition here)? Or, instead, will your therapist choose to focus on the environmental and societal factors that have influenced your personal developmental trajectory? Before any of us engage a therapist, or any of us engage in the practice of therapy, we should consider the theoretical underpinnings that form the foundation of our helping professionals’ worldview. Obviously there’s a good reason why individual therapists choose the theories they do… conscious consumers should not be afraid to ask for the reason.

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When change occurs in my personal life, I usually attribute it to entropy. The illusion of being able to control my environment is tempting to say the least, but I believe self realization comes as a result of accepting that you have little or no control over the sequence and timing of developmental change. For me, clinical counseling represents a vehicle by which individuals learn to control reactions to a constantly changing chaotic world. My goal for all of my clients, and for myself, is to be able to embrace change and employ it as a springboard to drive structural, functional, and behavioral growth. To me, it’s almost irrelevant as to whether it is “governed by nature (i.e., genetics, maturation or biological structures) or nurture (i.e., child rearing methods, cultural values, planned learning experiences, unplanned life events).” (Bergen, 2008, p. 3) Regardless of the governance, the reality is that we have the opportunity to change tomorrow by acting today.

As I continue to process and refine my own theoretical perspective on human development, my expectation is that the theory provides individuals I serve with an outcome that can be predicted with reasonable certainty. For example, if we engage dialectical behavior therapy (DBT) I should be able to predict with reasonable certainty that you will experience an increase in mindfulness. If DBT fails to produce that result, I am content to attribute that failure to individual variability… to me, it doesn’t much matter if it’s nature or nurture… so long as we identify the point of failure and try again (this time modified to fit the individualized participant). Perhaps we could integrate religious and metaphysical concepts into the effort to increase the traction of our DBT efforts. Or, perhaps we will go in a parallel direction and focus more on interpersonal effectiveness or emotion regulation since they are contributing factors to the overall efficacy of DBT? Maybe we abandon DBT altogether and take another angle? The options are endless… but a theory some provide some direction, some purpose, to the decisions that are made in that process.

Applied Behavior Analysis (ABA) meets all of my expectations for a theoretical construct. ABA is committed to resolving real world issues not theoretical quandaries. Practical importance is at the forefront of my interest. ABA focuses on the behavior that needs improvement, not just any behavior. Good results must be measurable, conceptually systematic, and able to be replicated. Finally, a good theory must possess generality of the in the respect that it lasts over time and it appears in environments other than the one in which… it was implemented. (Cooper, Heron, & Heward, 2007, p. 18)

As a sidebar…

Does anyone out there have any real world examples of entrainment? (juxtaposition of one or more systems to form new combinations)

What strategies do you use to ensure you are employing “activated knowledge” as defined by Bergen (2008) on page 33?

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References

Bergen, D. (2008). Human development: Traditional and contemporary theories. Upper Saddle River, NJ: Pearson Prentice Hall.

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Response to: Growing up bipolar: ‘Nobody was on my side’ (CNN)


CNN published an insightful piece on Bipolar Disorder today (see link below) that hit a few significant points that have been under expressed here of late…  I have to credit the author (Elizabeth Landau) because she acknowledged that the spike in bipolar disorder diagnosis rates could be attributed to our collective focus on the disorder.

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I would also like to demonstrate support for the ‘mind over meds’ concept that is purveyed when the author suggests “as a first line of defense, family support and therapy would be given to the child and problematic environments — be it home or school — would be improved, and then medication would be given as needed.”  Medication should be a last resort, especially when it comes to psychotropic drugs.  It is widely acknowledged that there is no psychotropic drug that comes without significant potential for side effects.  Regardless of our theoretical perspective… Cognitive Behavioral – Dialectical Behavioral – Gestalt – Group – Psychoanalytic – Talk… or the other variations of therapy… I would submit that the best case scenario for medication is as an adjunct treatment… adjunct to traditional therapy services.  What’s not to like about no side effects?

Last, but certainly not lest, CNN provides another voice to the growing crowd of providers who are frustrated by a general lack of access when it comes to individuals without insurance.  All men are created equal. Those five words used to mean something.  Unfortunately, those of us who are wading through the fragmented mess we call a mental health system in the United States know… it’s exactly what the author of the article purports it to be…

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Link to the original article:

http://www.cnn.com/2010/HEALTH/08/30/bipolar.kids/index.html?hpt=C2

Comparing Conversion Disorder to Dissociative Disorders


Conversion disorder falls within the broader category of somatoform disorders in the DSM-IV-TR (2000).  Essential features include one or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological condition, accompanied by psychological factors judged to exacerbate or initiate the onset.  The symptoms are not intentionally produced (as in Factitious Disorder of Malingering), nor can they be fully explained by a general medical condition.  Typically someone diagnosed with Conversion Disorder will present with motor deficit (paralysis), sensory deficit (deaf, blind), seizures/convulsions, or some combination of the above (mixed).  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 498)

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“The essential feature of the dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 519)  This may manifest in an inability to recall information in dissociative amnesia, or the presence of two or more distinct identities in dissociative identity disorder (DID, formerly Multiple Personality Disorder or MPD).  It may also present as a recurrent feeling of being detached from one’s body or mental processes, as in depersonalization disorder.

Dissociative and conversion disorders share symptoms, may have similar antecedents (high rates of trauma), and both suggest neurological dysfunction.  “If both conversion and dissociative symptoms occur in the same individual (which is common), both diagnoses should be made.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 497)  Conversion disorder is classified as a dissociative disorder in the IDC-10.  In a recent and comprehensive comparison of the two disorders, Brown and associates have strongly suggested that “moving pseudo-neurological symptoms (i.e., conversion disorder) back to the dissociative fold would make better sense of the empirical database, help conceptual integration of related areas, and, last but not least, finally bring concordance across DSM and ICD taxonomies.”  (Brown, Cardeña, Nijenhuis, Sar, & van der Hart, 2007, expression CONCLUSIONS AND IMPLICATIONS)  Despite differences in presentation (outlined above), I inclined to agree with proponents of including conversion disorder as part dissociative disorders in the DSM-V.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Brown, R. J., Cardeña, E., Nijenhuis, E., Sar, V., & Van der Hart, O. (2007, Sep/Oct). Should conversion disorder be reclassified as a dissociative disorder in DSM-V. Psychosomatics, 48(5), 369-379. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1333420861&sid=4&Fmt=4&clientId=4683&RQT=309&VName=PQD

Factitious Disorders | Factitious Disorder by Proxy | Munchausen Syndrome


Factitious Disorders and Factitious Disorder by Proxy covers the disorders formerly known as Munchausen Syndrome.  By definition, factitious disorders are a condition in which symptoms are feigned or created by the patient.  This might manifest in by someone complaining about a pain that doesn’t exist, or it might result in the client drinking a pint of Drain-o to get sick.  Generally speaking, the goal or objective is to assume the “sick role,” and subsequently obtain the benefits that are generally imbued on them as a result.

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Do kids start lying as early as age 2?  It would appear that they learn to lie about the same time they learn how to talk.

“As children, many of these patients experienced rejection, mistreatment, and parental loss.  For them, the hospital provides a haven or refuge.”  (Netherton, Holmes, & Walker, 1999, p. 305-306)  I have trouble identifying with this… you couldn’t pay me to go to a hospital; I avoid them like I avoid the plague.  I don’t know if most “normal” people feel like that, but it’s about the last place I would consider a refuge…

Factitious disorders are best differentiated from malingering by accessing the goal.  “Only when the sick role becomes part of the child’s life can the diagnosis of factitious disorder be considered.”  (Netherton et al., 1999, p. 306)  So, factitious disorders represent more than malingering in a sense that they are persistent efforts to appear sick, without any apparent short term goal other than to obtain the sick role status.  If that means the client has to lie, they often do.  The symptoms are intentionally produced, and the patient can voluntarily make them appear or disappear.  In that respect, they differ from somatoform disorders because they are voluntary, not involuntary.  Where malingerers pretend to be sick, somatoform sufferers feel doomed to be sick, and sufferers of factitious disorder creating symptoms that to ensure that status.  (Netherton et al., 1999, p. 307)

Treatment begins with confrontation.  A “normal” person (I am not sure I can ever write the word normal again without the “”) would probably stop lying right there and the problem would be solved.  Unfortunately, that confrontation does not typically resolve the issue with factitious disorders.  I was surprised to see that the relationship typically improves after that process occurs though… I wonder if there is a sense of relief on the part of the client that they have been caught.

The “by proxy” version of Factitious Disorder is fascinating.    Check out this video… I couldn’t believe my eyes! http://www.youtube.com/watch?v=UVLqADEdrig&feature=related People who suffer from this disorder make their kids sick, or engage in deceptive behavior to make them appear sick… ultimately in an effort to gain attention or sympathy.  The average time taken to uncover the proxy diagnosis was estimated to be 14.9 months!  (Netherton et al., 1999, p. 310)  Although the text makes a case for more widespread general knowledge, that process has unfortunately led to many false identifications and misdiagnosis.  One surefire way to identify the proxy diagnosis is to remove the child from the care of the parent or caregiver and see if their issues persist.  Another (more controversial, if that’s even possible) method is to covertly attempt to videotape the act of child abuse.  Imagine the legal ramifications if you were wrong!  It’s a pretty hefty gamble; we could potentially lose a license over a misdiagnosis like that.

How does mandatory reporting play into this “by proxy” diagnosis.  I mean, if you even suspect this as a possible diagnosis, don’t you have to report it?

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Dissociative Disorders | Dissociative Amnesia | Dissociative Fugue | Dissociative Identity Disorder (DID) | Depersonalization Disorder | Dissociative Disorder NOS


Dissociative Disorders as a category generally encompass dissociative amnesia, dissociative fugue, dissociative identity disorder (DID), depersonalization disorder, and dissociative disorder not otherwise specified (DDNOS).  DDNOS is a residual category intended to capture clinical presentations of DID that fail to meet the full criteria, including derealization unaccompanied by depersonalization, dissociative states in individuals who have been subjected to sever coercive persuasion (makes no sense), dissociative trance disorder, medically unexplained loss of consciousness, stupor, or coma (conversion disorder?); and Ganser syndrome (nonsense, balderdash, approximate answers; syndrome).   The irony is that DDNOS represents the majority of clinical presentations, suggesting that some reorganization of the category is needed since the residual diagnostic label gets more airplay than the flagship disorders.

Structural dissociation of the personality translates into “a lack of integration among two or more psychobiological subsystems of the personality as a whole system, each endowed with at least a rudimentary sense of self.”  One person, multiple personalities; where personalities are defined as “the dynamic organization within the individual of those psychophysical systems that determine his characteristic behavior and thought.”  (Blaney & Millon, 2009, p. 453)

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“Dissociative Amnesia is the sudden inability to recall personal information that is too extensive to be explained by ordinary forgetfulness.”  (Blaney & Millon, 2009, p. 457)  Of note, is that the diagnosis requires that no other dissociative disorders be present or diagnosed… as a result, this is often a precursor to or a marker for more pervasive dissociative disorders.  Like dissociative fugue, it can be a symptom or a syndrome.  Blaney and Millon embrace an etiological background that includes environmental factors (lack of support, exposure to trauma) with biological predispositions (personal and social factors, low integrative capacity).

Dissociative fugue is similar to tic disorder in the respect that it can be either a symptom or a disorder in and of itself.  Fugue’s onset is relatively sudden in most cases, resulting when an individual travels away from one’s customary home or work.  The result is an inability to recall the past, similar to amnesia, but fugue is predicated by travel.  The amnesia aspect indicates that there may be a strong division between dissociative parts of the personality, and the normally inactive emotional personality (EP) totally dominates the apparently normal personality (ANP).  (Blaney & Millon, 2009, p. 458)

The spectrum of Dissociative Disorders culminates with Dissociative Identity Disorder (DID).  Two or more distinct identities or personality states must be present, and they must recurrently take control of the person’s behavior.  There are some inherent problems with the DID diagnosis, particularly because there is no clarity on the range of what is considered “complete control.”  The list of comorbid disorders with DID read like a laundry list (it is the longest one I have seen to date).  PTSD, self-mutilation, aggressive and suicidal behaviors, impulsivity, repetitive abusive relationships, conversion symptoms, mood, substance-related, sexual and eating disorders, as well as personality disorders are among them.  (Blaney & Millon, 2009, p. 458)  I have never seen comorbity suggestions include entire categories!

Depersonalization Disorder represents persistent or recurring episodes of “feelings of detachment or estrangement from one’s self, while reality testing remains intact.”  (Blaney & Millon, 2009, p. 459)  This reminded me of schizophrenia.  “Out of body experiences” coupled with feeling like your living in a dream or a movie sound like schizophrenia to me.  Maybe I am off here though.

DDNOS is a grab bag of disorders, including the most prevalent disorder in the dissociative family.  Specifically, I am referring to presentations of DID symptoms but are much less “extreme.”  “The identities or dissociative parts exhibit less elaboration and autohomy and are commonly not active or not as active in daily life as some dissociative parts of the personality in patients with DID.”  (Blaney & Millon, 2009, p. 459)  It’s basicly “DID Lite.”  They experience partial intrusion instead of complete switches in executive control.

Dissociative States in individuals who have experienced extreme coercive persuasion doesn’t make any sense, it sounds like it is describing the category, not a separate entity?  I’d bet it gets scratched from the DSM-V.

Dissociative Disorder that “are indigenous to particular locations and cultures” is a fascinating concept.  I am again reminded of the cultural nature of somatization disorders, and I have to wonder if this is just a difference in cultural interpretation, or if indeed cultural traditions have an impact on it’s presentation.

Dissociative stupor should be under somatoform disorders, or conversion disorder should be classified as a dissociative disorder.  They broke up a suited pair.

Of all the theories of dissociation disorders, the one I identified with the most was the “theory of structural dissociation of the personality.”  The basic premise “involves the role of evolutionary prepared actions systems as the underlying psychobiosocial systems that become dissociative in an individual.  The categorization of the systems into 1) systems that promote adaptive functioning and 2) mammalian action systems for defense against bodily threat make sense to me.  The distinction between the ANP and the EP makes sense to me.  It makes me wonder, can you provoke the EP into “coming out” by threatening someone with DID?

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Adverse Childhood Experiences | ACE Study | Effects on the Autonomic Nervous System (ANS)


The ACE Study focuses on the effects of “Adverse Childhood Experiences” on adult health.  It would suffice to say that the epidemiological data they accumulated suggests an overwhelming correlation between childhood trauma and our health as adults.  My initial reaction is one of shock and awe, although I was equally surprised by the depth and breadth of research to support their findings.   (Cavalcade Productions, Inc. [CP], 2004)

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Palaszynski and colleagues concluded that adverse childhood experiences could produce long-term effects on a number of biological systems, including the endocrine, nervous, immune, and cardiovascular systems.  Generally speaking, they found that any system involved in the acute stress response system could be affected.  (Palaszynski & Nemeroff, 2009)  Since examining all of these biological systems is beyond the scope of this short article, we will focus on the Autonomic Nervous System (ANS).

Chartier and associates (2009) found empirical evidence that childhood abuse exacerbated chronic health conditions through a number of mechanisms, including increased autonomic nervous system or hypothalamic-pituitary-adrenal axis activity.  Other research, conducted by Farrugia and Fetter (2009), implicated the brain processing centers for pain, emotion, and other autonomic physiologic behavior; suggesting that relative proximity and plasticity (less specific) functioning the sub-cortex of the brain may account for a cross-over of neurological activity.  Chapman, Dube, and Anda (2007) found that the “autonomic nervous system and hypothalamic-pituitary-adrenal axis hyper-reactivity may be a consequence of childhood abuse, heightening the subsequent risk for depression.”  Furthermore, dysregulation of the hypothalamic-pituitary-adrenal axis has been documented in individuals with other forms of psychological stress, including childhood abuse.  (Brotman, Golden, & Wittstein, 2007)

Although the depth of the research that has been conducted so far is impressive, additional research is needed to add clarity and depth to the current compendium of information we have at our disposal.

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References

Brotman, D. J., Golden, S. H., & Wittstein, I. S. (2007,  Sep 22-Sep 28). The cardiovascular toll of stress. The Lancet, 370(9592), 1089-1101. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1367219481&sid=5&Fmt=4&clientId=4683&RQT=309&VName=PQD

Cavalcade Productions, Inc. . (Producer). (2004). The ace study: Childhood trauma and adult health [Video]. Available from http://idcontent.bellevue.edu/content/CAS/HS/513/ace_study1.html.

Chapman, D. P., Dube, S. R., & Anda, R. F. (2007, May). Adverse childhood events as risk factors for negative mental health outcomes.  Psychiatric Annals, 37(5), 359-364. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1275282761&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Chartier, M. J., Walker, J. R., & Naimark, B. (2009, May). Health risk behaviors and mental health problems as mediators of the relationship between childhood abuse and adult health. American Journal of Public Health, 99(5), 847-855. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1683162771&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Farrugia, D., & Fetter, H. (2009, Jul). Chronic pain: Biological understanding and treatment suggestions for mental health counselors.  Journal of Mental Health Counseling, 31(3), 189-201. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1835886381&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Palaszynski, K. M., & Nemeroff, C. B. (2009, Dec). The medical consequences of child abuse and neglect. Psychiatric Annals, 39(12), 1004-1010. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1938538251&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD