Title: Understanding Somatization in the Practice of Clinica
1Understanding 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
2Noran Clinic Neuropsychology
3Purpose 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 high- utilizing
patients could be a decided boon to our field and
to healthcare in general.
4Purpose 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.
5Organization of workshop
- History
- Nosology
- Epidemiology
- Developmental/Etiological considerations
- Neuropsychological assessment
- Treatment approaches
- Management
6A 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
7History
- Ancient Egyptians
- wandering uterus
- Hippocrates
- hysteria
- Galen (2nd century)
- sexual deprivation in females
8History (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)
- - Charcots hysteria (inherited functional CNS
disease) - - Freudian (Janetian, Breuerian) or
psychological conceptualizations of hysteria - - Modern day, patient-oriented
conceptualizations -
9History (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
10History (cont.)
- Robert Whytt (17141766)
- Spinal reflexes responsible for nervous
conditions. - Nerves were a common affliction from the late
18th to early 20th century. - Paul Briquet (17961881)
- Comprehensive listing of symptoms in 1859
monograph based on 400 (mostly) female patients
from the Salpêtrière hospital in Paris from
1849-1859. - Reaffirmed Sydenhams 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
Briquets syndrome in recognition of the French
psychiatrists seminal contributions.
11History (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
12History (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.
13History (cont.)
- Pierre Janet (18591947)
- Janet's work with Charcot led to his development
of ideas about the connection between
subconscious states and earlier traumatic events.
- Janets 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 (18561939)
- 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.
14History (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 ones
mind/head. - This is a very unpopular notion with patients, as
suggested by Shorter (1992) and the tide has
seemingly turned
15History (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.
16History (cont.)
- In other words
- Its 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 publics sensibilities (and
maybe even reality).
17Nosology
- 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.
18Nosology (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
19Nosology (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.
20Nosology (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.
21Nosology (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).
22Nosology (cont.)
- All contemporary systems borrow heavily from
Briquets (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.
23Nosology (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) -
24Nosology (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)
25Nosology (cont.)
- 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).
26Nosology (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?
27Nosology (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.
28Nosology (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.
29Nosology (cont.)
- Alternative descriptive systems
- Medically unexplained symptoms
- Ultimately atheoretical
- Popular with neuropsychologists (Binder
Campbell, 2004) - Abridged somatization (Escobar et al., 1987)
- Based on this groups 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
30Nosology (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
31Nosology (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.
32Nosology (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.
33Nosology (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.
34Nosology (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.
35Nosology (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.
36Nosology (cont.)
- Patients 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 - - its all in your head
- - trivializing the patients 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, well note the existence of these different
views, and move on.
37Epidemiology
- 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
38Epidemiology (cont.)
- Prevalence estimates for DSM-IV somatoform
disorders - DSM-IV Diagnosis Prevalence Estimate
- Somatization Disorder .2 to 2
- Undifferentiated Somatoform Disorder not provided
- Conversion Disorder lt.1 to 3
- Pain Disorder "common" (10-15 work-related
disability for back pain alone) - Hypochondriasis 4 to 9 in general medical
practice - Body Dysmorphic Disorder "more common than
previously thought"
39Epidemiology (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 -
40Epidemiology (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. -
41Epidemiology (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
42Epidemiology (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
43Epidemiology (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).
44Epidemiology (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).
45Epidemiology (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 (n90) 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
46Epidemiology (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.
47Epidemiology (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 (18-44) and older (gt60 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
48Epidemiology (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.
49Epidemiology (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
50Epidemiology (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
51Epidemiology (cont.)
- Masi et al., (2000) attempted to identify
prevalence of somatic symptoms in children and
adolescents (n162) 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
52Epidemiology (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
53Epidemiology (cont.)
- Summary
- Somatoform diagnoses tend to be fairly uncommon
in large-scale 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
54Epidemiology (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.
55Epidemiology (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 ones
head.
56Developmental/Etiological Considerations
- In the DSMIII (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.
57Developmental/Etiological Considerations (cont.)
- Biologically Oriented Theories
- Functional 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"
58Developmental/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/neurotransm
itter 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.
59Developmental/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.
60Developmental/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-epilepticseiz
ures.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.
61Developmental/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.
62Developmental/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 Darwins
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?
63Developmental/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.
64Developmental/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.
65Developmental/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.
66Developmental/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.
67Developmental/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.
68Developmental/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.
69Developmental/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 Annas nonfunctional arm
was symbolically representative of guilt about
his death - Conversion continues to be invoked in medical
contexts, generally synonymously with
somatization
70Developmental/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
71Developmental/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.
72Developmental/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.
73Developmental/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.
74Developmental/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.
75Developmental/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.
76Developmental/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.
77Developmental/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
78Model of Adult Attachment
Model of Self (Dependency)
Positive (Low) 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
Model of Other (Avoidance)
adapted from Bartholomew Horowitz (1991)
79Developmental/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.
80Developmental/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.
81Developmental/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).
82Developmental/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.
83Developmental/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.
84Developmental/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.
85Developmental/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-indivi
dual 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.
86Neuropsychological 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.
87Neuropsychological 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)
88Neuropsychological 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 arent sensitive enough to
pick up on the cognitive dysfunction that exists. - Maybe deficits dont exist (frequently the
opinion in the forensic realm).
89Neuropsychological 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, Gouvie