Transcript the Presentation

Understanding Somatization in
the Practice of Clinical Neuropsychology
Greg J. Lamberty, PhD, ABPP-Cn
Noran Neurological Clinic
Minneapolis, MN
5th Annual Conference of the American
Academy of Clinical Neuropsychology
June 7 - 9, 2007
Denver, Colorado
Noran Clinic Neuropsychology
Purpose and goals

The purpose of this workshop is to provide practitioners with
the conceptual understanding and the clinical tools needed to
put a “constructive” approach into practice.

Neuropsychologists are encouraged to look upon these
difficult patients as an opportunity to employ their unique
skills in assessment, case conceptualization, and
education/intervention.

With the current focus on “best practices” and cost-effective
treatments, improving the management of notoriously highutilizing patients could be a decided boon to our field and to
healthcare in general.
Purpose and goals (continued)

Thus, this workshop is not about the neuropsychology of
somatization or the somatizing patient per se, but about
effectively identifying, assessing, educating, and referring
such patients for appropriate management and intervention.
Organization of workshop
 History
 Nosology
 Epidemiology
 Developmental/Etiological
considerations
 Neuropsychological assessment
 Treatment approaches
 Management
A basic definition of our subject matter
 Somatization,
somatoform symptoms, &
somatizing patients
1) the clinical report of multiple somatic complaints that
are medically unexplained
2) significant functional impairment or disruption in every
day life
History

Ancient Egyptians
wandering uterus
Hippocrates
hysteria
Galen (2nd century)
sexual deprivation in
females
History (cont.)

Somatization in the 18th & 19th centuries

E. Shorter (1992) – From Paralysis to Fatigue
Somatization as a function of prevailing medical culture
- Spinal irritation (back pain & associated peripheral symptoms)
- Dissociation (somnambulism, catalepsy, & multiple personality)
- Motor hysteria (paralysis)
- Charcot’s hysteria (inherited functional CNS disease)
- Freudian (Janetian, Breuerian) or psychological conceptualizations of
hysteria
- Modern day, patient-oriented conceptualizations
History (cont.)

Thomas Sydenham
(1624-1689)
“English Hippocrates”
Proponent of observational methods
Hysteria not only an affliction of women
Hysteria is a product of the “mind”
History (cont.)

Robert Whytt
(1714–1766)
Spinal reflexes responsible for “nervous” conditions.
“Nerves” were a common affliction from the late 18th to early 20th century.

Paul Briquet
(1796–1881)
Comprehensive listing of symptoms in 1859 monograph based on 400 (mostly)
female patients from the Salpêtrière hospital in Paris from 1849-1859.
Reaffirmed Sydenham’s view of hysteria as a nervous condition, not solely seen
in women, and characterized by many predisposing factors.
In DSM-III somatization disorder was co-named “Briquet’s syndrome” in
recognition of the French psychiatrist’s seminal contributions.
History (cont.)

Treatment of nervous disorders
Contemporary medical establishment focused on methods to bring humors
into balance, like…
bleeding
blistering
purging
Meanwhile, in France, there was a burgeoning spa industry offering special
curative waters, wraps, poultices, and massages.
The curative powers of these treatments has never passed peer-review
muster, but the spas live on. Go figure…
History (cont.)

Jean Martin Charcot
(1825-1893)
Father of modern neurology.
His interest in treating hysterical patients with magnetism and hypnotism saw his
views evolve.
Janet & Freud took hysteria to a more psychological plane, but Charcot held fast
in his belief of the neurologic basis of hysteria.
History (cont.)

Pierre Janet
(1859–1947)
Janet's work with Charcot led to his development of ideas about the connection
between subconscious states and earlier traumatic events.
Janet’s thinking about suggestibility, dissociation, and the subconscious is widely
acknowledged to have predated ideas popularized by Freud in the late 19th
and early 20th centuries.

Sigmund Freud
(1856–1939)
Freud's conceptualization of "conversion" became a dominant viewpoint in
understanding the nature of hysteria.
Even today, conversion disorder retains a place, although arguably, as a
diagnostic entity in DSM-IV.
History (cont.)

The struggle against dualism
DSM-III, perhaps unwittingly, reinforced the dualistic thinking of the
past that separated mind and body.
That is, by definition, symptoms seen in the somatoform disorders are
medically unexplained and by default, psychological, or “in one’s
mind/head.”
This is a very unpopular notion with patients, as suggested by Shorter
(1992) and the tide has seemingly turned…
History (cont.)

The struggle against dualism (continued)
Advances in imaging technology and cognitive neuroscience have
made it possible to convincingly demonstrate relationships between
neurophysiology and behavior/mental illness (Damasio, 1994; Ledoux,
1996; Schore, 1994).
Unfortunately, despite modern-day neuroscientists’ elegant attempts to
convince us of the inseparability of mind and body, for many stigma
and shame cling to mental illness and psychological difficulties.
Fortunately, emotion has become the new final frontier for prominent
neuroscientists. It seems like that this will lead to a better
understanding of the complex interplay between emotions, somatic
symptoms, and neuropsychiatric symptoms.
History (cont.)

In other words…
It’s Not All in Your Head (Asmundson & Taylor, 2005)
“How worrying about your health could be making you sick – and what you can do
about it.”
Marketing of clinical services is becoming cognizant of the public’s
sensibilities (and maybe even reality).
Nosology

There is a clear lack of consensus regarding nosology in
somatoform syndromes. Much of what we are interested in
is clinically defined…
hysteria
somatization
somatoform disorders
functional somatic syndromes
medically unexplained symptoms

Different systems define the problem in different ways, but
none of them meet reasonable criteria for an adequate
diagnosis.
Nosology (cont.)
for example…
 Hypertension

Diagnosis
Chronically elevated blood pressure
Systolic and diastolic pressures over 140 and 90 mm Hg

Treatment
Dietary changes
Exercise
And, of course, drugs
Nosology (cont.)

DSM-III (APA, 1980) – a more descriptive, atheoretical system
as compared to previous psychodynamically oriented systems
(DSM I/II)
Somatoform disorders
In addition to somatization disorder, several relatively rare and specific
syndromes were included, based mainly on the presence of unexplained
physical symptoms (conversion, hypochondriasis, BDD, pain disorder).
Somatization disorder
“Hysteria” as a neurotic disorder in DSM-II (APA, 1968) was replaced in
DSM-III (APA, 1980) by somatization disorder, which focused on the
clinical description of “multiple somatic complaints” to the exclusion of a
presumed neurotic etiology.
Nosology (cont.)

The descriptive/pathological approach to mental disorders
positioned psychiatry favorably among traditional medical
specialties.
Schizophrenia, mood, and anxiety disorders have benefited because
of a more clear sense of their biological underpinnings.
This has allowed biomedical and pharmaceutical research to
proceed, with generally positive findings.

Somatoform disorders have suffered a different fate.
Because a “real” physical cause is, by definition, lacking, there has
not been much interest in identifying therapeutics for these
disorders, except as they overlap with mood or anxiety disorders.
Nosology (cont.)
In fact, the lack of clear biological underpinnings for the somatoform
disorders has led some to encourage the abolition of the category
(e.g., Mayou et al., 2005) in favor of a more basically descriptive or
“pragmatic” approach (Engel, 2006).
Nosology (cont.)

All contemporary systems borrow heavily from Briquet’s
(1859) monograph (summarized by Mai & Mersky, 1980)
430 patients seen over a 10 year period.
Etiologic factors were youth, female gender, “affective” and
“impressionable” temperament, family history of the disorder, low
social class, migration, sexual licentiousness, situational difficulties,
and poor physical health.
Briquet considered the "effective part of the brain" the final common
pathway that mediated these causative agents.
In treatment, Briquet emphasized the importance of an improvement in
social circumstances and the need to minimize environmental
problems.
Nosology (cont.)

Somatization disorder per DSM-IV (APA, 1994)
A. A history of many physical complaints beginning before age 30 years that
occur over a period of several years and result in treatment being sought
or significant impairment in social, occupational, or other important areas
of functioning.
B. Each of the following criteria must have been met, with individual
symptoms occurring at any time during the course of the disturbance:
(1) four pain symptoms: a history of pain related to at least four different
sites or functions (e.g., head, abdomen, back, joints, extremities, chest,
rectum, during menstruation, during sexual intercourse, or during
urination)
Nosology (cont.)
(2) two gastrointestinal symptoms: a history of at least two gastrointestinal
symptoms other than pain (e.g., nausea, bloating, vomiting other than
during pregnancy, diarrhea, or intolerance of several different foods)
(3) one sexual symptom: a history of at least one sexual or reproductive
symptom other than pain (e.g., sexual indifference, erectile or ejaculatory
dysfunction, irregular menses, excessive menstrual bleeding, or vomiting
throughout pregnancy)
(4) one pseudoneurological symptom: a history of at least one symptom or
deficit suggesting a neurological condition not limited to pain (conversion
symptoms, such as impaired coordination or balance; paralysis or localized
weakness; difficulty swallowing or lump in throat; aphonia; urinary
retention; hallucinations; loss of touch or pain sensation; double vision;
blindness; deafness; seizures; dissociative symptoms, such as amnesia; or
loss of consciousness other than fainting)
Nosology (cont.)
C.
Either (1) or (2):
(1) after appropriate investigation, each of the symptoms in Criterion B
cannot be fully explained by a known general medical condition or the
direct effects of a substance (e.g., a drug of abuse, a medication)
(2) when there is a related general medical condition, the physical
complaints or resulting social or occupational impairment are in excess of
what would be expected from the history, physical examination, or
laboratory findings
D. The symptoms are not intentionally produced or feigned (as in Factitious
Disorder or Malingering).
Nosology (cont.)

The major diagnostic systems have experimented with the
somatization issues in various ways…
DSM-IV requires 8 symptoms from 4 symptom groups.
ICD-10 requires 6 symptoms from 2 symptom groups.
DSM and ICD systems have “residual” or “undifferentiated” categories
that require fewer overall symptoms to be reported.

But is there any validity to these approaches?
Nosology (cont.)

Basically… No.

Several studies have failed to indicate better diagnostic
precision as a function of differing sets or number of
symptoms (Gureje & Simon, 1999; Liu, Clark, & Eaton, 1997;
Simon & Gureje, 1999).

A factor analytic study (Liu, Clark, & Eaton, 1997) highlighted
the chronic nature of unexplained symptoms, regardless of
the diagnostic scheme.
Nosology (cont.)

In general studies have highlighted…
Variability in individual symptom report over time (Lieb et al., 2002)
Variability in the consistency (accuracy) of the report of lifetime
symptoms (Gureje & Simon, 1999; Simon & Gureje, 1999)

Thus, specific criteria do not influence the basic description
of somatizing patient groups (i.e. chronic and unexplained).
But they may influence epidemiological estimates of different
somatoform syndromes.
This observation highlights the fact that current diagnostic criteria are
heuristically valuable, but quite limited from a practical clinical
standpoint.
Nosology (cont.)
Alternative descriptive systems

Medically unexplained symptoms
Ultimately atheoretical
Popular with neuropsychologists (Binder & Campbell, 2004)

Abridged somatization (Escobar et al., 1987)
Based on this group’s experience with the Epidemiological Catchment
Area (ECA) studies of the early 1980s
A “less restrictive operational definition of the somatizer”
4+ unexplained symptoms for men; 6+ such symptoms for women
Nosology (cont.)

Multisomatoform disorder (Kroenke et al., 1997)
DSM somatization disorder too restrictive, but undifferentiated
somatoform disorder too inclusive
Three or more medically unexplained symptoms, regardless of gender
2+ year history of somatization symptoms

Functional somatic syndromes (Barsky & Borus, 1999)
“are characterized more by symptoms, suffering, and disability than by
disease specific, demonstrable abnormalities of structure or
function”
Nosology (cont.)

Functional somatic syndromes (cont.)
Attribution to a more specific cause or “disease”
Self-sustaining culture of patients and health care providers that
perpetuate the disabling and serious medical status of these
afflictions, contrary to a lack of compelling scientific or medical
support
A number of these conditions tend to come and go as a function of
public interest or compelling story lines, while others have a strong
following, even in the medical community.
Those with staying power include fibromyalgia, chronic fatigue
syndrome, multiple chemical sensitivities, and irritable bowel
syndrome.
Nosology (cont.)
Summary & suggestions for a new diagnostic approach

Mayou et al., (2005) suggest:
Redistribution of the various somatoform disorders among the
different axes of the DSM
-
For instance, hypochondriasis could be renamed “health anxiety”
and reclassified as an anxiety disorder.
Conversion could be classified as a dissociative disorder.
Somatization disorder might more accurately be considered a
personality disorder with mood and anxiety disorder features.
These suggestions are more consistent with clinical reality.
Nosology (cont.)

Mayou et al., (2005): (cont.)
Specific symptoms might reasonably be coded on Axis III as
"somatic symptoms" or "functional somatic symptoms.”
As noted, many studies have indicated that a less extensive level of
symptomatology is still associated with clinical impairment and
psychiatric comorbidity (Escobar et al., 1987; Kroenke et al., 1997).
While it might seem to be a matter of semantics, the fact that
patients presenting with even a few somatoform symptoms tend to
show marked increases in health care utilization, should be enough
to encourage those in clinical and health policy fields to consider
changes to the current diagnostic scheme.
Nosology (cont.)

Avoiding dualism
As discussed earlier, many have criticized the nature of the DSM
typology (Engel, 2006; Kirmayer et al., 2004; Mayou et al., 2005;
Sharpe & Carson, 2001).
Diagnoses within this category basically call for ruling out physical
causes for the symptoms presented thus making such symptoms de
facto “mental” or “psychogenic.”
The "mental" view of somatoform symptoms has been an obstacle
to more effective treatment of such symptoms by primary care
personnel (Mayou et al., 2005; Sharpe & Carson, 2001; Stone et al.,
2002), perhaps due to stigma or a sense of a lack of seriousness.
Nosology (cont.)

Cultural awareness
Some argue that (DSM-defined) somatoform disorders are not
appreciative of cultural differences and unique syndromes with
which they would appear to conflict (González & Griffith, 1996;
Kirmayer, 1996; Kirmayer et al., 2004; Mayou et al., 2005).
González and Griffith (1996) note that the DSM appears to make a
distinction between mental disorders that are determined by biology
(e.g., depression, schizophrenia) and those that are more culturally
influenced.
Such disorders are much more likely to show variability from one
culture to another and, in fact, may not be regarded as pathological
at all. This view emphasizes the value of clinical description rather
than forcing a diagnostic label when it is unlikely to serve a
utilitarian purpose.
Nosology (cont.)

Patient’s acceptance of diagnostic labels
Some are concerned about the effects of proffering a diagnosis of
somatization, hysteria, or medically unexplained symptoms, as all of
these labels as tend to carry a strong connotation of “mental illness.”
The use of diagnoses that are thought to convey a more objective
sense of symptomatology raises patient defenses and makes it difficult
to understand the nature of problems
- “it’s all in your head”
- trivializing the patient’s problems
- questioning their character
Whether patients’ concerns about this issue should be considered is
something that clinicians will have markedly different views about. For
now, we’ll note the existence of these different views, and move on.
Epidemiology

The epidemiology of somatization is obviously tied to the
systems used in clinical and research contexts.

Accordingly, there is substantial variability in terms of
prevalence estimates of various somatoform disorders.

DSM estimates are typically among the lowest (most
conservative) with respect to prevalence of somatoform
disorders. However, the “science” behind them seems a bit
lacking…
Epidemiology (cont.)
Prevalence estimates for DSM-IV somatoform disorders
DSM-IV Diagnosis
Somatization Disorder
Undifferentiated Somatoform Disorder
Conversion Disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder
Prevalence Estimate
.2% to 2%
not provided
<.1% to 3%
"common" (10%-15% work-related disability
for back pain alone)
4% to 9% in general medical practice
"more common than previously thought"
Epidemiology (cont.)

Population based studies
National Institutes of Mental Health Epidemiologic Catchment Area
(ECA) study (Reiger et al., 1984)
- 20,000 people from five urban settings in the United States
- lifetime prevalence of somatization disorder was 0.13%
Escobar et al. (1987) used the Los Angeles ECA data
- .03% of 3132 met DSM-III criteria for somatization disorder
- 4.4% met criteria for “abridged somatization”
- Changing the criteria slightly increased prevalence dramatically
- Also, significant differences in the reporting of depending upon
gender, ethnic background, and pre-existing psychiatric diagnoses
Epidemiology (cont.)

Primary care studies

Gureje and Simon (1997) examined longitudinal data
from a large (26,000 cases) international (14 countries)
study examining psychological problems in primary health
care settings.
- Prevalence estimates between 1% and 3% depending upon whether
DSM or ICD-10 criteria were employed.
- Symptom reports were extremely variable over time with overall
rates of DSM-IV somatization disorder that were similar when assessed
12 months later, but fewer than half of those initially diagnosed
continued to report lifetime symptoms consistent with a somatization
diagnosis.
Epidemiology (cont.)

Escobar et al. (1998) examined their abridged somat.
construct in a university affiliated primary care clinic
- Abridged somatization in this sample was around 20%
- Strong associations with various forms of psychopathology and
physical disability

Kroenke et al. (1997) examined their multisomatoform
disorder (MSD) construct in 1000 pts from 4 primary care
clinics
- 8% of this primary care sample was diagnosed with MSD
- showed similar health-related impairments to patients with mood
and anxiety disorders
- more disability days, clinic visits, and greater difficulty as perceived
by clinicians
Epidemiology (cont.)
- Therefore, MSD is a valid diagnosis and has an independent effect
on functional difficulties apart from comorbid psychiatric diagnoses

Barsky, Orav & Bates (2005) examined self-reported
somatoform symptoms and their association with medical
care utilization
- In an eligible sample of 1456 patients, 299 (20.5%) were given a
provisional diagnosis of somatization
- "somatizers" were noted to utilize both inpatient and outpatient
services at roughly twice the level noted for non-somatizing patients
- Barsky et al., (2005) suggest that the incremental medical care costs
associated with somatization alone (i.e., not including comorbid
psychiatric illness) is approximately $256 billion a year
Epidemiology (cont.)

Smith et al., (2006) used a chart review procedure with
HMO patients to identify “high-utilizing MUS patients.”
- Of 206 patients that were identified, 60.2% had a “nonsomatoform
diagnosis,” meaning that they did not meet criteria for full or abridged
somatization based on the DSM-IV, but rather had one or more
psychiatric diagnoses.
- 4.4% of the selected sample met full DSM-IV criteria for a
somatoform diagnosis, while 18.9% met criteria for abridged
somatization disorder.
- 23.3% of the high-utilizing MUS sample met criteria for full or
abridged somatization (somatoform-positive), while 76.7% did not
(somatoform-negative).
Epidemiology (cont.)
- The somatoform-negative group showed less overall anxiety,
depression, mental dysfunction, psychosomatic symptoms, and
physical dysfunction than did the somatoform-positive group.
- Patients who utilize services frequently and report MUS are not
necessarily a homogenous group. Patients that have MUS, but do not
meet criteria for a somatization diagnosis are more likely to be
characterized by lower levels of depression and anxiety than a wide
range of psychiatric, functional, and disability issues (like the
somatoform positive group).
Epidemiology (cont.)

Neurology clinic studies

Carson et al., (2002)
- 300 new referrals to a regional neurology clinic in Scotland
- Neurologists rated patients’ symptoms to the extent that they were
explained by physical findings.
- 30% (n=90) had substantially unexplained symptomatology
- Patients with lower "organicity" ratings consistently showed a higher
number of median physical symptoms and pain complaints.
- 70% of patients in the "not at all explained" group had a depression
or anxiety disorder, compared to 32% of patients in the "completely
explained" group
Epidemiology (cont.)

Carson et al., (2003)
- A follow-up study by Carson et al., (2003) reported on 66 of the 90
patients with significantly unexplained symptoms
- 14% of these patients rated themselves as much or somewhat worse
- 63% reported no change or modest improvement
- 23% of the patient's were "much better”
- 54% of patients with unexplained symptoms at baseline showed no
improvement or worsening symptoms eight months later
- The best predictor of poor outcome at follow-up was greater physical
difficulty at baseline. In no case did an actual neurologic cause emerge
as the reason for the originally unexplained symptoms at follow-up.
Epidemiology (cont.)

Fink, Hansen, & Sondergaard (2005)
- Of 198 first time neurology referrals, 61% had at least one medically
unexplained symptom
- 35% met diagnostic criteria for ICD-10 somatoform disorder
- Outpatients were more likely than inpatients to have a somatoform
diagnosis
- Women were more likely than men to have somatoform diagnoses
- The gender difference was much more pronounced in younger (1844) and older (>60 years old) patients, with little gender difference in
the middle age group (45-59)
- Among patients with somatoform diagnoses, 60.5% also had another
psychiatric diagnosis
Epidemiology (cont.)
- Collectively, patients referred to neurology clinics tended to meet
criteria for somatoform diagnoses about 30% of the time.
- Within this patient group, there were more females, more psychiatric
diagnoses, and higher level of physical dysfunction and disability.
- This is in contrast to primary care settings in which roughly 20% of
patients tend to meet either full or abridged criteria for somatoform
disorders.
Epidemiology (cont.)


Pediatric studies
Fritz, Fritsch, & Hagino (1997) reviewed literature from the previous
10 years with regard to conceptual and clinical reports of somatization
in children
-a
lack of developmentally appropriate schemas and a call for more
thorough outcome studies

Campo et al., (1999) examined a group of pediatric "somatizers" to
determine risk for greater psychopathology, functional impairment, and
utilization of health services
- parental reports of pain related symptomatology to identify
somatizing children (4-15 y.o.) from a pediatric primary care clinic
Epidemiology (cont.)
- children with and without significant somatization were compared on
a number of variables including demographic, psychopathologic,
functional status, and utilization
- adolescents, females, minority individuals, children from urban
practices, nonintact families, and families with lower parental
education
- heightened risk of clinician and parent identified psychopathology,
poor school performance, perceived health impairment, and increased
utilization
Epidemiology (cont.)

Masi et al., (2000) attempted to identify prevalence of somatic
symptoms in children and adolescents (n=162) referred to a pediatric
neurology/psychiatry practice for EBD
- Somatic symptoms were reported in 69.2% of the sample
- Headache was most common, reported in 50.6% of sample
- Younger children showed higher reporting of abdominal complaints,
and there were no gender differences in overall symptom report
- Patients with anxiety and depression reported a higher level of
somatic symptomatology, particularly headache
- authors concluded that somatoform symptoms should be considered
as a possible indication of unidentified psychiatric disorder
Epidemiology (cont.)

Campo and Fritz (2001) offered recommendations for managing
pediatric somatization based on the scant literature available and
essentially drawing from the adult literature
- emphasize cognitive behavioral approaches
- treatment of comorbid psychopathology like depression and anxiety
Epidemiology (cont.)
Summary

Somatoform diagnoses tend to be fairly uncommon in largescale epidemiologic studies

The prevalence of these disorders in more selected primary
care and neurology settings increases dramatically,
particularly when less stringent criteria are employed

Across a number of different studies, 20 to 30% of primary
care and specialty clinic referrals present with significant
somatoform symptoms
Epidemiology (cont.)
Summary (cont.)

Within this broad group there tend to be higher numbers of
women, minorities, and individuals with significant comorbid
psychopathology (typically depression and anxiety dis.).

Some researchers have emphasized the comorbidity issue
and suggest that somatoform disorders are simply a
different manifestation of an underlying psychiatric disorder.

Others have determined that somatoform symptoms are
independently problematic and the cause of significant
utilization and health care expenses.
Epidemiology (cont.)
Summary (cont.)

DSM-IV definitions of somatoform disorders lack coherence,
and this fact makes it difficult to make recommendations for
individuals comprising the somatoform disorders as a group.

Ironically, “psychiatric” diagnoses like somatization present
infrequently (as a primary diagnosis) in psychiatry clinic
settings.

Perhaps the “biologicalization” of psychiatry has unwittingly
contributed to dualism in this diagnosis. That is, there are
biological mental disorders like depression, and then there
are those that are merely psychological, or in one’s head.
Developmental/Etiological Considerations
In
the DSM–III (APA, 1980) Somatoform Disorders are
described thusly,
“The essential features of this group of disorders are physical symptoms
suggesting physical disorder (hence, Somatoform) for which there are no
demonstrable organic findings or known physiological mechanisms and
for which there is positive evidence, or a strong presumption, that the
symptoms are linked to psychological factors or conflicts.”
This
strongly suggests that SD essentially lack material
substance, thus forcing a dualistic view that separates the
“demonstrably organic” from the “psychological.”
Developmental/Etiological Considerations (cont.)
Biologically
Functional
Oriented* Theories
Somatic Syndromes (FSS)
- Because SD (as defined in DSM-III and beyond) are explicitly without
a biological cause, some researchers in psychosomatics have focused on
a range of FSS, presumably as distinct from SD
- Instead of trying to account for the nature and complexity of SD
patients, subgroupings of symptoms, dysfunction in specific bodily
systems, or reactions to various environmental toxins have become
focal points that have effectively diverted scrutiny from the individual to
the "disease"
Developmental/Etiological Considerations (cont.)
- Current conceptualizations of various FSS aim to be more integrative,
but the theme of protestation of the “real” physical nature of disorders,
like fibromyalgia and chronic fatigue, is unmistakable
- From the National Fibromyalgia Association website
http://www.fmaware.org/about.htm
“Most researchers agree that FM is a disorder of central processing with
neuroendocrine/neurotransmitter dysregulation. The FM patient experiences pain
amplification due to abnormal sensory processing in the central nervous system. An
increasing number of scientific studies now show multiple physiological abnormalities in
the FM patient, including: increased levels of substance P in the spinal cord, low levels of
blood flow to the thalamus region of the brain, HPA axis hypofunction, low levels of
serotonin and tryptophan and abnormalities in cytokine function.”
Developmental/Etiological Considerations (cont.)
- From the Chronic Fatigue and Immune Dysfunction Syndrome
(CFIDS) Association of America, http://www.cfids.org
- No clear-cut cause of CFIDS is offered and it is acknowledged that it
is essentially a diagnosis of exclusion.
“CFIDS is characterized by unrelenting exhaustion, muscle and joint pain,
cognitive disorders, and other symptoms. Many people with CFIDS are denied
disability benefits because doctors and employers wrongly believe they are lazy
or have a mental illness rather than a serious physical condition.”
“Research on CFIDS is being conducted on many fronts, but the cause of the
disease remains a mystery.”
Developmental/Etiological Considerations (cont.)
- In contrast, other FSS advocacy groups are acknowledging the
importance of psychological factors in the genesis and maintenance of
these disorders. For example…
International Foundation for Functional Gastrointestinal Disorders
http://www.aboutibs.org/
Nonepileptic Seizures http://www.non-epilepticseizures.com
- These groups seek to educate the public on a range of problems
that are distressing, sometimes disabling, and not clearly related to
structural brain or CNS abnormalities.
Developmental/Etiological Considerations (cont.)
- This suggests some movement toward a greater acceptance of the
complexity and nature of these problems.
- As suggested in the Nosology section, the importance of providing a
message that patients can hear is not to be underestimated and these
sites provide some guidance in this regard.
Developmental/Etiological Considerations (cont.)
Evolutionary
psychology (EP)
- While not a biological theory per se, EP posits a theoretical
framework to understand false illness signaling
- EP represents the application of Darwin’s theory of natural selection
to psychological mechanisms
- An EP approach to somatization asks whether false illness signaling
represents an innate psychological mechanism triggered by situational
exigencies
- Does somatization represent a behavioral polymorphism that bestows
survival value?
Developmental/Etiological Considerations (cont.)
- Of interest is the repeated finding of psychopathy or antisocial traits
such as substance abuse in male relatives of somatizing females.
- Mealy (1995) suggested that somatization was evidence for
secondary psychopathy; females with partial psychopathic traits
produce false illness signals in order to access resources during
particularly stressful times.
- Psychopathy or not, does false illness signaling afford females an
evolutionary advantage during “insecure” (in attachment theory terms)
times, relative to their male counterparts?
- This does not rule out SD in men, but the empirical reality is that SD
is predominately associated with female status.
Developmental/Etiological Considerations (cont.)
Behaviorally
Oriented Theories
- Behavioral theories of somatization are reductionistic and relatively
simple, facilitating leaner research designs and more straightforward
statements about results.
- Behavioral models have been most widely applied in pain
management settings (Fordyce, 1976; Keefe & Gil, 1986; Turk,
Meichenbaum, & Genest, 1983).
- Operant conditioning (OC) principles (Fordyce, 1976) are employed in
which points are reinforced for displaying healthy behaviors, while
consequences are placed on pain behaviors, excessive medication use,
avoiding movement, or seeking other treatments.
Developmental/Etiological Considerations (cont.)
- The OC paradigm can be applied more broadly to somatoform
symptoms in a manner that allows us to conceptualize the production of
physical symptoms as operant behavior with a specific goal.
- Thus, various somatoform symptoms are used to secure
reinforcement in potentially many different forms.
- The connection between some somatoform symptoms and
reinforcement is not always clear which makes it difficult to distinguish
between SD, factitious disorders, and malingering.
- In this model, volition (willfulness) is irrelevant and these disorders
are functionally the same. All involve the symptom production for a
certain effect, or to obtain reinforcement the nature of which is often
difficult to determine.
Developmental/Etiological Considerations (cont.)
The
case of mild traumatic brain injury
- On the biologically oriented disorder side, mTBI is often characterized
via a physical injury/illness model that is wide ranging and attempts to
account for the many (specific & nonspecific) symptoms reported
(Bigler, 2003; Mittenberg & Strauman, 2000).
- In contrast, mTBI patients can be seen as a classic example of
operant behavior. Various symptoms are put forth by patients with the
end goal of securing some manner of reinforcement.
- Of course, it is likely the case that some elements of both models are
operative in the modal mTBI case, at different points in time.
Developmental/Etiological Considerations (cont.)
Psychoanalytically
oriented theories
- Much of our popular understanding of SD has its theoretical genesis
in the work of Janet, Breuer, and Freud.
- Stekel (1925), a Viennese psychoanalyst, coined the term
“somatization” to refer to a process whereby a deep-seated neurosis
could be expressed through a physical disorder.
- Brown (2004) provides a review of psychological mechanisms
purported to underlie MUS. He notes that MUS have traditionally been
based on two concepts popularized in the late 19th/early 20th centuries
– dissociation and conversion.
Developmental/Etiological Considerations (cont.)
Dissociation
- Janet (1907) explains that some patients’ attention narrows when
they are exposed to traumatic events. As a result of this narrowing,
individuals will attend to a limited amount of sensory information.
- Eventually, some sensory information can be neglected if the
individual develops a pattern of concentrating on a limited number of
symptoms, in the case of conversion, physical symptoms.
- Over time, the lack of other compelling input causes a person to
interpret subjective experiences as actual perceptions, which are then
awakened in an automatic fashion under many different circumstances.
Developmental/Etiological Considerations (cont.)
Conversion
- Breuer & Freud (1895/1991) referred to the notion that unconscious
emotional conflicts are literally converted into bodily symptoms
representative of prior trauma or the nature of that trauma.
- Conversion allows the individual to deal with distress without directly
discussing a conflict or bringing it into conscious awareness .
- Anna O. – Studies on Hysteria (1895)
-
-
Reportedly unable to use one arm
Pt. reported cradling her dying father in this arm
Breuer speculated that Anna’s nonfunctional arm was symbolically
representative of guilt about his death
Conversion continues to be invoked in medical contexts, generally
synonymously with somatization
Developmental/Etiological Considerations (cont.)
Conversion
- While most of us have heard of Anna O and the tidy concept of
conversion, Breuer also noted…
-
-
intermittent paraphasias
visual difficulties
deafness
headache
suicidal thoughts
anxiety
paresis/plegia
hallucinations
agitation
absence-like spells
Developmental/Etiological Considerations (cont.)
Conversion
- In other words, Anna might also have met criteria for somatization
(even DSM criteria!).
- In fact, it is rare to see a circumscribed neurologic-appearing deficit in
isolation. With minimal probing, the likelihood of unearthing a history
of other neuropsychiatric symptoms/diagnoses is quite strong.
- Perhaps one of principal environs in which something resembling true
conversion is seen – military service.
Developmental/Etiological Considerations (cont.)
- In clinical practice conversion, hysteria, and somatization are often
used interchangeably across many clinical settings, suggesting
considerable penetration of traditional psychodynamic views, as well as
considerable staying power.
- The broadening of the conversion hysteria concept became the focus
of Freud's work and developed into what we now know as classical
psychoanalytic theory.
- Even the layperson understands that unconscious conflicts underlie all
manner of neuroses, regardless of how they present. The lack of
falsifiability of these notions was always problematic, until the
emergence of a more integrative theoretical perspective.
Developmental/Etiological Considerations (cont.)
Attachment
& early developmental theories
- Attachment theory focuses on the nature and quality of early infant
relationships and how that affects subsequent emotional health and
behavior.
- Bowlby (1969), who was influenced by both Freud and Darwin,
assumed strong biologically mediated links in these relationships.
- Unlike the abstract models of the early psychoanalysts, attachment
theorists put forth a strong psychobiological model which suggested
that early experiences influenced neural development, as well as
subsequent behavior.
Developmental/Etiological Considerations (cont.)
- The appeal of the attachment model is its developmental focus as
contrasted with the work of Freud and Darwin, who focused their work
on adults or mature adult species.
- The integrative nature of attachment theory, as well as its
developmental perspective, is therefore a welcome synthesis of many
important ideas developed over the past century or more.
- Attachment theorists were not specifically concerned with
somatization, but the incorporation of biological and psychodynamic
theories makes it attractive for researchers and clinicians.
There are now well-validated measures that allow researchers to
quantify constructs that have emerged from attachment theory.
Developmental/Etiological Considerations (cont.)
- Numerous recent studies have been published examining the
relationship between attachment styles and different symptom
presentations (e.g., Ciechanowski, Walker, Katon & Russo, 2002;
Waldinger, Schulz, Barsky & Ahern, 2006; Waller & Scheidt, 2006;
Wearden et al., 2003; Wearden et al., 2005).

Attachment theory for dummies…
- People develop “internal working models” based on their early experiences
with important others.
- These cognitive (representational) models of self and others influence how
an individual interacts with others and the nature of their relationships.
Developmental/Etiological Considerations (cont.)

Ainsworth (1967) provided early descriptions of different
patterns of infant attachment, referring to three primary
patterns - Secure, Anxious (Avoidant or Resistant), and
Disorganized/Disoriented
- These patterns were identified through the use of Ainsworth's
"strange situation procedure," which became the standard for
observing the interaction between infants and mothers/caregivers.

Bartholomew & Horowitz (1991) presented a schema
identifying two fundamental kinds of adult attachment;
secure and insecure.
Developmental/Etiological Considerations (cont.)

Bartholomew & Horowitz (1991) presented a schema
identifying two fundamental kinds of adult attachment;
secure and insecure
- Secure attachment is the result of an individual having positive
models of both their self and others. Insecure attachments result from
the other three possible combinations in a basic 2 x 2 matrix
Model of Adult Attachment
Model of Self
(Dependency)
Positive
(Low)
Model of Other
(Avoidance)
Negative
(High)
Positive
(Low)
Cell I
Secure: comfortable
with intimacy and
autonomy
Cell II
Preoccupied:
preoccupied with
relationships
Negative
(High)
Cell IV
Dismissing:
dismissing of intimacy
and counter dependent
Cell III
Fearful: fearful of
intimacy and socially
avoidant
adapted from Bartholomew & Horowitz (1991)
Developmental/Etiological Considerations (cont.)

Ciechanowski et al., (2002) examined a large group of female primary
care HMO patients with respect to attachment style (Bartholomew &
Horowitz, 1991), somatization symptoms, and health care utilization.
- Preoccupied and fearfully attached individuals showed a higher level
of symptom reporting compared to securely attached individuals.
- Patients with preoccupied attachment showed higher levels of
utilization and primary care costs, while fearfully attached patients had
the lowest utilization and costs.
- Despite the fact that preoccupied and fearfully attached individuals
both reported a high level of symptomatology, their utilization of
services was quite different.
Developmental/Etiological Considerations (cont.)

Schmidt, Strauss and Braehler (2002) gave normal individuals a measure
of attachment and a measure of subjective complaints.
- The highest level of physical symptomatology was seen in anxiously
attached individuals, while individuals with secure attachment did not
show a high level of specific symptom report.

Waller and Scheidt (2006) focused on the issue of affect regulation and
how it relates to attachment theory.
- Dismissing attachment was related to restricted expression of
emotions (alexithymia), and this pattern seemed to be strongly
represented among those with somatoform disorders.
Developmental/Etiological Considerations (cont.)

Brown, Schrag & Trimble (2005) examined the occurrence of dissociation
in somatizing patients as well as its relation to childhood interpersonal
trauma and early family environment
- A general finding of chronic emotional abuse being strongly related
to the development of somatization disorder
“Many people with somatization disorder are exposed to an early
environment that is emotionally cold, harsh, and characterized by
frequent criticism, insults, rejection, and physical punishment.” (Brown,
Schrag & Trimble, 2005, p. 904).
Developmental/Etiological Considerations (cont.)

Waldinger et al., (2006) also looked at the issue of childhood trauma
within the framework of attachment theory.
-Childhood
trauma was related to higher levels of somatic symptom
report and insecure attachment.
-In
women, fearful attachment mediated the link between childhood
trauma and somatization, while this relationship was not seen in men.
-Thus,
in women childhood trauma is related to somatization because it
hastens insecure adult attachment. In men, trauma and attachment
are both predictors of somatization, but they do so independently.
-Regardless
of gender differences, childhood trauma influences
individuals’ interpersonal relating skills.
Developmental/Etiological Considerations (cont.)

Wearden et al., (2005) extended earlier findings using the model of
attachment described in Bartholomew and Horowitz (1991).
Fearful and preoccupied attachment styles were associated with
increased symptom reporting.
-
-Alexithymia
has an additive effect on symptom reporting in fearfully
attached individuals.
Developmental/Etiological Considerations (cont.)

In general terms, a strong relationship has been noted between insecure
attachment styles and reporting of physical symptoms.

The fundamental relationship between (presumably) early relational
trauma and subsequent problems with all manners of interpersonal
communication, affect regulation, and attachment seems well
established.

Schore (1994, 2001, 2002) has written expansively on “infant relational
trauma” and its effect on the development of the right hemisphere,
integrating findings from the trauma literature and developmental
psychopathology that point to the right hemisphere's dominance in early
development.
Developmental/Etiological Considerations (cont.)

These models emphasize the dynamic nature of early emotional
experiences, maturation of neural circuitry, and the resulting effect on
adaptive coping (Schore, 2002).

The flexibility of such models allows for the common clinical observation
of the fact that the same trauma results in markedly different clinical
symptomatology on an individual-by-individual basis.

It seems likely that somatization, postconcussive syndrome, and
maladaptive coping in general likely fit somewhere on the spectrum of
early relational trauma.

Insights into these matters might well be obtained by examining
attachment styles, alexithymia, and affect regulation as a more routine
aspect of our clinical assessments.
Neuropsychological Assessment
 Cognitive
dysfunction in somatization, medical patients, and
normal samples
- Studies of specific neurocognitive deficits within these disorders are
rare.
- Symptom reports tend to be more strongly associated with
neuropsychiatric distress than actual pathology or identified cognitive
deficit.
- The relationship between reported cognitive difficulties and
somatoform symptoms, particularly those involving emotional
distress, is not specific to somatoform disorders.
Neuropsychological Assessment (cont.)
For example…

Type 1 vs. Type 2 diabetes (Brands et al., 2006)

Breast cancer survivors (Castellon et al., 2004)

Chronic distress and dementia (Wilson et al.,
2007)
Neuropsychological Assessment (cont.)
 Thus, the relationship between reported cognitive difficulties and
neuropsychiatric distress is well known, as is the lack of
relationship between such reports and actual performance.
 Therefore, neuropsychological complaints might serve as a sort of
cognitive “idiom of distress.”
 Maybe our measures aren’t sensitive enough to pick up on the
cognitive dysfunction that exists.
 Maybe deficits don’t exist (frequently the opinion in the forensic
realm).
Neuropsychological Assessment (cont.)
Base rates of cognitive complaints
 Postconcussive symptoms in normal samples
- Studies show that “PCS” symptoms are fairly common in
normal individuals, or that symptoms reported by patients are not
far outside the range of normative expectation. (Fox et al., 1995; Gouvier,
Uddo-Crane, & Brown, 1988; Gouvier et al., 1992; Hilsabeck, Gouvier, & Bolter, 1998; Martin,
Hayes, & Gouvier, 1996; Roberts et al., 1990)
- Thus, in both clinical and normal samples there is a range of
symptom acknowledgement, and normalcy is clearly not an
either/or distinction.
Neuropsychological Assessment (cont.)
Psychological disturbance in somatization

While cognitive correlates of somatization are difficult to characterize
conceptually, psychological correlates are well captured by our most
familiar measures.

MMPI-2 (Butcher et al., 1989). Most commonly used measure of
personality and psychopathology in the world.
Scale 3 (Hysteria) -- developed to "identify patients who were
having hysterical reactions to stress situations" (Graham, 2006)
- Effective in identifying individuals who report high levels of specific
somatic symptoms including things like chest pain, nausea, and
headaches.
- Other items involve denial of psychological or emotional problems
and naïveté/optimism with regard to how they view others. 60 items
comprising Hy in the MMPI-2 were all carried over from the original
MMP I.
Neuropsychological Assessment (cont.)

Scale 1 (Hypochondriasis) – originally developed to assess
preoccupation with the body and disease states. High scorers
tend to be characterized as having somatoform disorders
(Graham, 2006).

RC 1 (Somatic Complaints) – similar to scale 1 and the HEA
(health concerns) content scales. Patients with elevations report
lots of physical symptoms and are unlikely to see these
complaints as having a psychological basis. There is also a
greater level of depression and anxiety symptomatology.

“Conversion” or somatization V – elevations on scales 1 and 3,
with correspondingly lower scale 2. Complaints include pain
(head, neck, back, chest), pseudoneurological sx (tremors,
numbness, tingling), and vague somatoform sx (fatigue,
dizziness, ‘malaise’).
Neuropsychological Assessment (cont.)
FBS
(Lees-Haley, English & Glenn, 1991)

Items selected to be sensitive to exaggeration of personal injury.

A reliable and valid indicator of somatic symptom exaggeration in
forensic contexts.

“…empirical research has established the utility of the scale in identifying
potentially exaggerated claims of disability, primarily in the context of
forensic neuropsychological evaluations.”

In forensic evaluation contexts an elevated FBS score suggests a greater
likelihood of exaggeration and/or malingering.

Outside this context, elevated FBS scores are less clear.
Neuropsychological Assessment (cont.)

Because a patient acknowledges extreme somatoform sx does not, de
facto, suggest that they were necessarily doing so for some kind of
secondary gain.

In summary, the FBS scale might reasonably be thought of as an
indication of "somatic distress" not unlike the ‘F’ scale as a more general
indicator of distress or "demoralization."

We truly are in need of “more studies” in this area, particularly with
non-litigating but somatization prone samples, such as…

Seemingly with every new journal volume, symptoms validity indices are
emerging including more recently
- Henry–Heilbronner Index (Henry et al., 2006)
- Response Bias Scale (RBS; Gervais, 2005; Gervais et al., in press)
Neuropsychological Assessment (cont.)
Clinical caveats…

The use of negatively charged labels can be alienating for patients.

The use of pejorative labels like "faking" and "malingering" run the risk
of prejudicing future providers and might limit treatment potential.

This is not to say that symptom exaggeration does not occur and that it
should not be labeled as such, but…
Neuropsychological Assessment (cont.)

Disorders/syndromes associated with somatization

Binder & Campbell (2004) provide a nice review of a number of different
FSS with MUS

Fibromyalgia, chronic fatigue, and chronic pain

Multiple chemical sensitivities/idiopathic environmental intolerances

Nonepileptic seizures

Postconcussive syndrome following mild traumatic brain injury

Multiple sclerosis/autoimmune disorders
Neuropsychological Assessment (cont.)

Fibromyalgia, chronic fatigue, and chronic pain
-
Historically, most studies in this area have reported performance
deficits on a range of neuropsychological measures involving basic
attention/concentration, information processing speed, motor speed
and agility, and working memory.
-
Major methodological shortcomings have involved a lack of
assessment of effort/motivation.
-
Studies examining symptom validity measures with patients
presenting with fibromyalgia, chronic pain, etc, have consistently
found an overrepresentation of invalid responding or at the very
least, suspect effort (Bianchini, Greve, & Glynn, 2005; Gervais,
Green, & Rohling, 2001; Gervais et al., 2002; Rohling et al., 2002).
Neuropsychological Assessment (cont.)
 Multiple chemical sensitivities/IEI
-
Overall, patients with MCS/IEI tend to show less in the way of
significant cognitive impairment as compared to other somatoform
disorders and their MMPI-2 clinical scales show a fairly characteristic
conversion V.
-
Two recent studies suggest differences in scores on the FBS in
litigating samples. Binder, Storzbach, & Salinsky (2006) reported a
very high level of FBS elevation while Staudenmayer & Phillips
(2007) reported relatively less significant elevation.
-
“…virtuous people without psychological or behavioral difficulties
beyond those subsequent to environmental exposure. Their bias is to
express stress and distress through somatization by emphasizing
physical symptoms and denying psychological symptoms” (p. 67).
Neuropsychological Assessment (cont.)
 Nonepileptic Seizures (NES)
-
Drane et al., (2006) compared NES and ES groups on a number of
measures and included a standardized symptom validity measure,
the Word Memory Test (WMT; Green, 2003).
-
Drane et al. (2006) found that over 50% of their NES sample failed
the WMT (similar to the limited available data in Binder, Storzbach,
and Salinsky, 2006), as compared to only 8% of the ES group.
-
In contrast, Cragar et al. (2006) found that 22% of patients with
epilepsy and 24% of patients with NES failed one or more effort
measures, while only 11% of a combined NES/ES group did so.
…more work to be done
Neuropsychological Assessment (cont.)
 Postconcussive syndrome (PCS)
-
It is clear that PCS following mild traumatic brain injury (mTBI) is a
clinical entity moderated by a number of factors, not the least of
which involve premorbid psychological functioning, litigation status,
and motivation/effort.
-
In this sense, PCS is much like many other somatic distress
disorders. In addition to legitimate cognitive deficits (Binder,
Rohling, & Larrabee, 1997; Dikmen et al., 1995; Frencham, Fox, &
Maybery, 2005), patients with PCS often complain of a range of
vague symptoms such as fatigue, confusion, dizziness, pain, and
emotional distress.
-
As such, attention to issues of effort and motivation are impacting
our understanding of the cognitive difficulties reported by these
patients and have set the standard for such studies in other SD.
Neuropsychological Assessment (cont.)
 Summary
-
While somatoform symptoms and disorders have been described for
hundreds of years, tools for the assessment of the psychological and
neuropsychological aspects of these syndromes have only recently
evolved to a point where we can accurately capture their essence.
-
Neuropsychological assessment and the insights of
neuropsychologists have been particularly helpful in advancing
diagnostic accuracy.
-
Like neuroimaging, EEG, and other technologies, current
neuropsychological measures are helping to bring somatoform
syndromes into a different light, improve conceptualization and
treatment, and move us closer to a goal of a less dualistic system of
understanding neuropsychiatric illness.
Treatment approaches
 Greater than 45% of all neuropsychologists responding to a recent wide
scale survey (Sweet et al., 2002) acknowledged that they did no
psychotherapy with patients without brain dysfunction
 The average amount of time spent engaging in psychotherapy across all
respondents and settings, and encompassing patients with and without
acquired brain dysfunction, was about seven hours per week (Sweet et
al., 2002). This does not necessarily mean seven hours of
psychotherapy, but rather seven hours in the provision of these services
 Thus, despite the fact that the vast majority of neuropsychologists are
trained in clinical psychology programs, the nature of
neuropsychological practice is such that treatment and psychotherapy
are decidedly secondary pursuits (Sweet et al., 2002; Sweet, Nelson, &
Moberg, 2006)
Treatment approaches (cont.)
 Biases about somatizing patients
- somatizing patients are lacking in insight and are “brittle” with respect
to understanding the essence of their problems
- they are poor prospects for psychotherapy, particularly insight-oriented
therapies
- the best that can be done for somatizing patients is to
pharmacologically treat symptoms of mood and/or anxiety disorders with
the hope that this will provide some general relief
- Ultimately, somatizing patients are considered difficult to treat because
of their lack of willingness to acknowledge the psychological nature of
their problems (Graham, 2006).
Treatment approaches (cont.)
 Therapy approaches
- Randomized controlled studies (Allen et al., 2002; Woolfolk & Allen,
2007) with SD are rare. Relevant studies have typically focused on
syndromes that do not correspond directly to DSM-based somatoform
disorders (i.e. functional somatic syndromes)
- Behavioral/cognitive behavioral treatments have been examined with a
much greater frequency as these approaches tends to be more
regimented and, as a result, easier to incorporate in larger scale studies.
-Treating Somatization, by Woolfolk and Allen (2007) emphasize the fact
many treatment approaches borrow from different theoretical
perspectives and integrative approaches seem to work best with SD
Treatment approaches (cont.)
 Cognitive behavior therapy (CBT) approaches
- CBT for somatization is based on the idea that patients are troubled
by how they think about events and symptoms. The basic goal of CBT
for FSS/somatization is to challenge and change the dysfunctional
thoughts and behaviors related to a patient’s somatoform symptoms
- A small number of reviews have described varied results with CBT in
somatoform disorders and FSS (Allen et al., 2002; Kroenke & Swindle,
2000, Tazaki & Landlaw, 2006; Woolfolk & Allen, 2007)
-CBT seems to enjoy the status of a treatment modality that various
professionals see as accessible and reasonable. That is, the ability to
specify a certain number of visits, specific content to be covered, and a
fairly simple overriding set of principles (identifying and changing
dysfunctional cognitions) seems a sensible approach
Treatment approaches (cont.)
 Cognitive behavior therapy (CBT) approaches
- Implementation of CBT programs has been a challenge because of
the nature of different referral settings. Primary care, gastroenterology,
and rheumatology clinics are all likely able to appreciate the benefit of
CBT to their patients. Whether they are able to adequately implement
such programs is another matter.
- Going forth, it will be critical to specify the structure and
implementation of CBT programs like that described by Woolfolk and
Allen (2007). Even given the extremely variable nature of CBT
interventions described in the literature over the past 10 years, results
are promising.
Treatment approaches (cont.)
 Psychodynamic approaches
- Psychodynamically oriented theories about somatization view
somatoform symptoms as a means for allowing emotional trauma to be
experienced in a less threatening or frightening manner
- As such, the goals of psychodynamic psychotherapy involve
facilitating the understanding of what underlies an individual’s
(physical) symptoms
- Short term dynamic therapy emerged in the 1960s and 1970s as a
method for taking advantage of the theoretical richness of ego
psychology and attachment theory in a more intense and expeditious
manner (Davanloo, 1995; Sifneos, 1987)
Treatment approaches (cont.)
- Aside from scattered case studies, there is little compelling empirical
work assessing the value of psychodynamic therapy approaches in the
treatment of somatization
- The exceptions have been a number of studies conducted with IBS
patients (Creed et al., 2003; Creed et al., 2005; Guthrie et al., 1991;
Svedlund et al., 1983)
- 101 patients were randomly assigned to either a standard medical
care group or a group that received 10 hour-long sessions of
"dynamically oriented individual psychotherapy" plus medical care
(Svedlund, 1983; Svedlund et al., 1983). The psychotherapy treatment
group showed significantly less somatic symptomatology both three
months and one year post treatment. The difference between groups
after one year was greater than it was immediately following
treatment, suggesting a strong and lasting effect of therapy
Treatment approaches (cont.)
- The psychotherapy treatment group showed significantly less somatic
symptomatology both 3 months and 1 year post treatment. The
difference between groups after 1 year was greater than immediately
following treatment, suggesting a strong and lasting effect of therapy
- Another group has reported several studies examining dynamically
oriented therapy with IBS patients (Guthrie et al., 1991; Creed et al.,
2005; Creed et al., 2003), with similar positive results.
- Treatment included therapy that focused on the relationship between
emotions and IBS symptoms, as well as relaxation training and
standard medical treatment.
Treatment approaches (cont.)
- Creed et al., 2003 examined the cost-effectiveness of psychotherapy
and paroxetine relative to standard medical care. Healthcare costs in
the year following tx were lowest for the psychotherapy group, second
lowest for the paroxetine group, and highest for standard medical care.
- As with the CBT approaches described above, ST dynamic therapy
approaches are often used along with ancillary methods involving
relaxation, education, and other professionals in different professional
contexts.
- There are considerable benefits to a focused and programmatic
approach to working with such patients. The benefits are increasingly
being demonstrated in the economic context, which will likely be the
prevailing standard in the future.
Treatment approaches (cont.)
 Integrative approaches
- The CBT and dynamic therapy treatment studies discussed are
integrative. That is, instead of adhering rigidly to a specific
psychotherapy model or philosophy, researchers and clinicians are
picking and choosing elements of other therapies that are known to
improve effectiveness
- Psychodynamically oriented treatments are incorporating more structure and time limits
as these facilitate improvement in patients given typical treatment environments and
constraints.
- Similarly, CBT-oriented treatments are incorporating more discussion and processing of
emotion and interpersonal content as this important material is often neglected in more
structured therapy approaches.
Treatment approaches (cont.)
 Integrative approaches
Interpersonal psychotherapy
- This approach focuses on problems in interpersonal relationships and
how these relate to individuals’ attachment needs
- It is a “dynamically informed” psychotherapy with a general goal of
improving interpersonal relationships and/or changing expectations
about those relationships
- Rather than focusing on specific symptoms or behaviors, IPT
emphasizes the importance of relationships and how individuals’ needs
are met through them (Stuart, 2006)
Treatment approaches (cont.)
- In somatization, insecurely attached individuals use physical
symptoms to convey their needs to others, often resulting in
dysfunctional communication (Stuart & Noyes, 2006).
- Like short term dynamic therapy, IPT is typically time limited and like
CBT, it is manual-based and focused on specific techniques.
Treatment approaches (cont.)
 Multi-modality approaches
Affective cognitive behavioral therapy (ACBT)
- Affective cognitive behavioral therapy (ACBT) is the moniker given to
the treatment program described by Woolfolk & Allen (2007) in their
book Treating Somatization: A Cognitive-Behavioral Approach.
- The book includes a manual for conducting a ten session CBT
program, an abbreviated program for progressive muscle relaxation, a
symptom severity scale, a somatic symptom questionnaire, and a list of
questions to encourage examination of cognitions.
Treatment approaches (cont.)
ACBT
“Training in emotional awareness and labeling of affect was a component
of the original 10-session version of this treatment. We came to believe
that, in order to be implemented effectively and used in conjunction with
cognitive methods in a comprehensive program of emotional regulation,
the emotion focused methods should be expanded and made more
central to the treatment. Also, in the 10-session version of the
treatment, the various cognitive and behavioral techniques are
implemented adequately, but the therapeutic attack on the sick role
tends to be preliminary and rather limited, as is the case with our
attempts in that format to make patients emotionally self-aware.”
(Woolfolk & Allen, 2007, p. 110)
Treatment approaches (cont.)
ACBT
- Certain therapist characteristics are identified as ideal, and are
acknowledged as rare in the experiences of the authors.
- Perhaps not surprisingly, therapists with only CBT background tend to
struggle with the portions of the program that deal with distinguishing
between thoughts and emotions.
- The authors suggest that narrowly trained individuals struggle with
“emotional nuance” and facilitating patients’ experience of their emotions
(Woolfolk & Allen, 2007).
Treatment approaches (cont.)
The future of treatment for somatization
As recently as 15 to 20 years ago, there was little in the way of an
organized presentation of ideas about how to treat patients with
functional somatic symptoms (Mayou, Bass, & Sharpe, 1995).
The book Treatment of Functional Somatic Symptoms was compiled to
provide “a comprehensive account of the treatment of functional somatic
symptoms…”
This section has reviewed some of this work, but to say that significant
advances have been made would be an overstatement.
The recent work by Woolfolk and Allen (2007) is a hopeful example of
what can be accomplished with a careful analytical approach that is
flexible and appreciative of the contributions of many different
professionals working with these complex patients.
Management
 All practice settings are different, but I see two fairly distinct
presentations where somatizing patients are concerned.
Stoic
- Typically referred by practitioners from various medical specialties
like neurology, rheumatology, infectious disease, and cardiology, but
also primary care (family practice, internal medicine) clinics,
chiropractic practices, and concerned family members.
- These patients appear stoic and matter-of-fact in conveying their
concerns, and they emphasize the objective and medical nature of
their problems.
- It is often the case that there has been an event (an accident or
injury) and the patient is simply not functioning at a level that is
characteristic of them.
Management (cont.)
Stoic (cont.)
- While it is not universally true, the stoic patient tends to have had
less overall contact with the medical system than the expressive
patient.
-rigid and obsessive personality style
-often quite specific about when their difficulties started
-“world was turned upside down” and all difficulties follow that event
difficult to sort through the reality of such assertions as the stoic patient will have
incorporated the historical truth of their experience in a way that makes it
unassailable in their mind
-In neuropsychology practices, the prototypical example of this
presentation is the modal mild TBI case
Management (cont.)
Stoic (cont.)
- The dramatic and almost literary quality of “life changing in an
instant” seems to be the main emotional hook for the stoic patient. To
the extent that any emotion is shown, it is when discussing the event.
“I didn’t ask for this” or “this is not me” are oft-repeated themes that
sometimes bring a brief, almost controlled outburst of emotions.
-Case: Ms. D
Management
Expressive
- Conform more to what was traditionally described as the hysterical
personality style. These patients are characterized by histrionic
personality features, depression and anxiety symptoms,
hypersensitivity, and dramatic remonstrations with regard to their
discomfort.
-The "neurotic style" of hysteria offered by Shapiro (1965) is
consistent with what had long been described in the psychodynamic
literature. That is, hysterical or somatizing patients were prone to
histrionics, flamboyance, and a vague cognitive style. Such patients
are common in psychiatry and general mental health practices.
Management
Expressive
- In seeming opposition to the stoic patient, the expressive patient
makes it abundantly clear that they are suffering. Their emotions are
very near the surface and it is sometimes difficult to get through
interviews because of this
-
Digressive, often sidetracked by details
Press to get in all the details before they are cut off or redirected
“Researchers” and “experts”
Intolerant of examiner incompetence & inexperience
- Case: Mr. M
Management
The Stoic—Expressive Continuum
- Stoic and expressive somatizing presentations could be considered
different ontogenetic forms within the somatizing patient.
- Stoic presentation may be more common in early interactions with the
health-care system
- Prohibitions about personal weakness are still prominent in this stage and
there is a general awareness that seeking a doctor's help is a significant
acknowledgment of personal weakness
- The stoic patient may well feel uncomfortable with seeking help in such a
direct fashion
- This does not mean that other forms of help-seeking have not been
attempted or even over utilized.
- In the early stages the somatizing patient may wear out their welcome with
loved ones or relatives. They may complain at work or use non prescription
medicines excessively
Management
The Stoic—Expressive Continuum
- By the time the patient comes to the attention of the health care
system they may feel like they have tried everything in their power to
affect some kind of therapeutic change
- The somatizing patient experiences a sense of liberation that they
are going to achieve some relief, or better still, a cure
- Most of the time, they simply do not. This dynamic is nicely
captured in the typical somatization profile on the MMPI-2
-When the stoic patient is not "cured" they are often encouraged to seek out
another specialist, or referred directly to one. The patient starts to attribute
their lack of progress to the incompetence of others or the complexity of their
affliction. Providers come to understand in short order that these patients are
simply not improving and they may quickly, in the eyes of the patient, change
their tune and place blame on the patient for not improving. This change of
attitude and approach is very often off-putting to the formerly stoic patient,
Management
The Stoic—Expressive Continuum
- Providers come to understand in short order that these patients are
simply not improving and they may quickly, in the eyes of the patient,
change their tune and may blame the patient for not improving.
- This change of attitude and approach is very often off-putting to the
formerly stoic patient, who can become more dramatic or demanding
in their presentation.
-They come to feel decidedly wronged and they become more vocal in
their self-advocacy. Before long, we have a more expressive or
demanding presentation and the prospects for successful treatment
would seem to be less positive as time passes.