Cognitive Behavioral Strategies for Somatization

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Cognitive Behavioral Strategies for Somatization

• Alejandro Interian, Ph.D.
• Assistant Professor
• Department of Psychiatry

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Defining Somatization

• Presentation of physical symptoms that are
• unexplained after medical/physical examination
  (i.e., medically unexplained symptom).
• associated with significant concern, distress or
  impairment
• as a manifestation of psychological distress.

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Latino-Somatization Connection?

• There are a number of studies that report higher
  rates of somatic complaints among Latino
  respondent with major depression
• In one example, the rates of somatization among
  females with major depression was (Escobar et
  al., 1987)
• 58 of Puerto Ricans
• 48 of Mexican-Americans
• 19 of Non-Hispanic Whites
• Culture is one aspect that guides the
  interpretation of symptoms

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Somatization Common across the board

• In medical settings, approximately one-third of
  physical symptoms lack an adequate medical
  explanation even after diagnostic work-ups
  (Kroenke, 2003).
• There is a clear association between levels
  somatic symptoms and levels of psychiatric
  distress (i.e., anx and dep Simon et al., 1996)
• This association is found worldwide and among all
  levels of education (though slightly strong among
  less educated individuals).
• Somatic symptoms are the most common idiom of
  distress worldwide

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Somatization REAL symptoms with emerging
evidence of physiological pathways

• Stress is associated with sympathetic nervous
  response, which includes increased heart-rate,
  breathing, and muscle tension. Also, includes
  diminished digestive functioning.
• CHRONIC stress is associated with suppressed
  immune functioning, due to increased release of
  cortisol.
• Brain-Gut Axis describes neural connections
  between the GI tract and the brain
• GI distress affect emotional centers of the brain
  and emotional (cognitive?) processing can affect
  GI functioning.

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CBT for somatization Assessment during therapy

• What symptoms do they experience? How often? How
  painful?
• What do they think to themselves when
  experiencing symptoms?
• What do they do to try and cope with symptom?
• What is their emotional reaction to the symptom?
• Try to elicit variation
• Are there times when their responses to the
  symptom are more mild?
• Get a detailed sense of their involvement in
  daily activities.
• Sleep patterns?

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CBT for Somatization Treatment Alliance

• Reflection
• Physical distress, Level of effort needed to
  cope, impact symptoms have had on their life
• Validate their symptom experience
• Avoid implying that symptoms are not real,
  exaggerated, etc.
• For case presented
• Reflect her sense of needing help, the impact of
  her symptoms, etc.
• What thoughts/feelings drives her need for help?
• You have told me about so many difficulties, the
  stressors, the pain. This has affected you to the
  point where you have thought about your funeral.
  At the same time, there is a part of you that is
  trying to get better because you are still in
  treatment, ________, and ____________.
• What are her concerns with the neurologists?

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CBT for Somatization Presenting the treatment
rationale

• Symptom variation provides teaching moments.
• Goal of treatment is to figure out how you can
  control symptoms.
• Describe the potential for stress to affect
  symptoms.
• Normal stress reaction in terms of sympathetic
  arousalthe bodys emergency mode.
• For example, digestive functions are turned off
  when stressed. If prolonged, results in digestive
  distress (e.g., pain, constipation, diarrhea).

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Behavioral Techniques

• Increased Activity Involvement
• Combats stress (minimize functioning in emergency
  mode)
• Improves overall mood (as we see in dep
  treatment)
• Provides Distraction from somatic symptoms
• Pain perception has a subjective
  componentimproved mood and distraction reduce
  the experience of pain
• Exercise has physiological effects that combat
  somatization and stress
• Do they get their daily dose of meaningful
  activity, productivity, and exercise?

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Behavioral Techniques (contd)

• Assertiveness Techniques
• What kinds of needs are asserted?
• What kinds of needs are not?
• Do they engage in combative communication
  patterns?
• Activity strategies and assertiveness help
  patients obtain reinforcement by behaviors other
  than illness behaviors.

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Relaxation Techniques

• Directly acts on physical symptoms, given its
  effects on breathing, heart rate, muscle tension,
  etc.
• Patients report benefit soon upon learning the
  technique
• Helps with stress management
• Includes Diaphragmatic Breathing, Progressive
  Muscle Relaxation, Biofeedback
• Practice, Practice, Practice.
• Practiced in session with patient, consecutively
  for a period of weeks (combined with practice at
  home).

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Sleep Strategies

• Establish consistent sleep patterns (same bedtime
  and waketime everyday)
• Go to bed only when sleepy (stimulus control)
• If not asleep within 20-30 minutes leave bed and
  return when sleep again (stimulus control)
• Bed is only for sleep and sex. No TV, reading,
  etc. (stimulus control)
• Comfortable sleep environment
• Avoid alcohol/caffeine during 6 hours before
  bedtime
• Exercise regularly, but not within 4 hours of
  bedtime

Woolfolk and Allen (2007)
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Cognitive Strategies

• Much like CBT for depression
• Looking for adaptability of thoughts
• Eliminating distortions
• Use somatic symptoms as anchors for examining
  thoughts
• Look for variations in adaptability of thoughts
  and discuss their effect
• Patients are likely to have difficulty
  identifying thoughts/emotions.
• Likely to have schemas that include health concern