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Title: Understanding Somatization in the Practice of Clinica


1
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
2
Noran Clinic Neuropsychology
3
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 high- utilizing
    patients could be a decided boon to our field and
    to healthcare in general.

4
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.

5
Organization of workshop
  • History
  • Nosology
  • Epidemiology
  • Developmental/Etiological considerations
  • Neuropsychological assessment
  • Treatment approaches
  • Management

6
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

7
History
  • Ancient Egyptians
  • wandering uterus
  • Hippocrates
  • hysteria
  • Galen (2nd century)
  • sexual deprivation in females

8
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)
  • - Charcots hysteria (inherited functional CNS
    disease)
  • - Freudian (Janetian, Breuerian) or
    psychological conceptualizations of hysteria
  • - Modern day, patient-oriented
    conceptualizations

9
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

10
History (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.

11
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

12
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.

13
History (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.

14
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 ones
    mind/head.
  • This is a very unpopular notion with patients, as
    suggested by Shorter (1992) and the tide has
    seemingly turned

15
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.

16
History (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).

17
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.

18
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

19
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.

20
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.

21
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).

22
Nosology (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.

23
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)

24
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)

25
Nosology (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).

26
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?

27
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.

28
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.

29
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 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

30
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

31
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.

32
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.

33
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.

34
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.

35
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.

36
Nosology (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.

37
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

38
Epidemiology (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"

39
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

40
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.

41
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

42
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

43
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).

44
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).

45
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 (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

46
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.

47
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 (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

48
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.

49
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

50
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

51
Epidemiology (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

52
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

53
Epidemiology (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

54
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.

55
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 ones
    head.

56
Developmental/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.

57
Developmental/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"

58
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/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.

59
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.

60
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-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.

61
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.

62
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 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?

63
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.

64
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.

65
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.

66
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.

67
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.

68
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.

69
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 Annas nonfunctional arm
    was symbolically representative of guilt about
    his death
  • Conversion continues to be invoked in medical
    contexts, generally synonymously with
    somatization

70
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

71
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.

72
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.

73
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.

74
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.

75
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.

76
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.

77
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

78
Model 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)
79
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.

80
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.

81
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).

82
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.

83
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.

84
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.

85
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-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.

86
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.

87
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)

88
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 arent sensitive enough to
    pick up on the cognitive dysfunction that exists.
  • Maybe deficits dont exist (frequently the
    opinion in the forensic realm).

89
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, Gouvie
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