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.

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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)

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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)

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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