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Understanding Somatization in the Practice of Clinical Neuropsychology

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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 Hippocrates Galen (2nd century)
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) - Charcot’s 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 (1714–1766) Paul Briquet (1796–1881)
Spinal reflexes responsible for “nervous” conditions. “Nerves” were a common affliction from the late 18th to early 20th century. Paul Briquet (1796–1881) Comprehensive listing of symptoms in 1859 monograph based on 400 (mostly) female patients from the Salpêtrière hospital in Paris from Reaffirmed Sydenham’s view of hysteria as a nervous condition, not solely seen in women, and characterized by many predisposing factors. In DSM-III somatization disorder was co-named “Briquet’s syndrome” in recognition of the French psychiatrist’s seminal contributions.

11 History (cont.) Treatment of nervous disorders bleeding
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 (1859–1947) Sigmund Freud (1856–1939)
Janet's work with Charcot led to his development of ideas about the connection between subconscious states and earlier traumatic events. Janet’s thinking about suggestibility, dissociation, and the subconscious is widely acknowledged to have predated ideas popularized by Freud in the late 19th and early 20th centuries. Sigmund Freud (1856–1939) Freud's conceptualization of "conversion" became a dominant viewpoint in understanding the nature of hysteria. Even today, conversion disorder retains a place, although arguably, as a diagnostic entity in DSM-IV.

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 one’s 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…
It’s Not All in Your Head (Asmundson & Taylor, 2005) “How worrying about your health could be making you sick – and what you can do about it.” Marketing of clinical services is becoming cognizant of the public’s sensibilities (and maybe even reality).

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.) Hypertension for example… Diagnosis Treatment
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 Briquet’s (1859) monograph (summarized by Mai & Mersky, 1980) 430 patients seen over a 10 year period. Etiologic factors were youth, female gender, “affective” and “impressionable” temperament, family history of the disorder, low social class, migration, sexual licentiousness, situational difficulties, and poor physical health. Briquet considered the "effective part of the brain" the final common pathway that mediated these causative agents. In treatment, Briquet emphasized the importance of an improvement in social circumstances and the need to minimize environmental problems.

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 Alternative descriptive systems
Nosology (cont.) Alternative descriptive systems Medically unexplained symptoms Ultimately atheoretical Popular with neuropsychologists (Binder & Campbell, 2004) Abridged somatization (Escobar et al., 1987) Based on this group’s experience with the Epidemiological Catchment Area (ECA) studies of the early 1980s A “less restrictive operational definition of the somatizer” 4+ unexplained symptoms for men; 6+ such symptoms for women

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 Summary & suggestions for a new diagnostic approach
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.) Patient’s acceptance of diagnostic labels
Some are concerned about the effects of proffering a diagnosis of somatization, hysteria, or medically unexplained symptoms, as all of these labels as tend to carry a strong connotation of “mental illness.” The use of diagnoses that are thought to convey a more objective sense of symptomatology raises patient defenses and makes it difficult to understand the nature of problems - “it’s all in your head” - trivializing the patient’s problems - questioning their character Whether patients’ concerns about this issue should be considered is something that clinicians will have markedly different views about. For now, we’ll note the existence of these different views, and move on.

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 <.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. % 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)
new referrals to a regional neurology clinic in Scotland - Neurologists rated patients’ symptoms to the extent that they were explained by physical findings. - 30% (n=90) had substantially unexplained symptomatology - Patients with lower "organicity" ratings consistently showed a higher number of median physical symptoms and pain complaints. - 70% of patients in the "not at all explained" group had a depression or anxiety disorder, compared to 32% of patients in the "completely explained" group

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 (>60 years old) patients, with little gender difference in the middle age group (45-59) - Among patients with somatoform diagnoses, 60.5% also had another psychiatric diagnosis

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 (n=162) referred to a pediatric neurology/psychiatry practice for EBD - Somatic symptoms were reported in 69.2% of the sample - Headache was most common, reported in 50.6% of sample - Younger children showed higher reporting of abdominal complaints, and there were no gender differences in overall symptom report - Patients with anxiety and depression reported a higher level of somatic symptomatology, particularly headache - authors concluded that somatoform symptoms should be considered as a possible indication of unidentified psychiatric disorder

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 one’s head.

56 Developmental/Etiological Considerations
In the DSM–III (APA, 1980) Somatoform Disorders are described thusly, “The essential features of this group of disorders are physical symptoms suggesting physical disorder (hence, Somatoform) for which there are no demonstrable organic findings or known physiological mechanisms and for which there is positive evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts.” This strongly suggests that SD essentially lack material substance, thus forcing a dualistic view that separates the “demonstrably organic” from the “psychological.”

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 “Most researchers agree that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation. The FM patient experiences pain amplification due to abnormal sensory processing in the central nervous system. An increasing number of scientific studies now show multiple physiological abnormalities in the FM patient, including: increased levels of substance P in the spinal cord, low levels of blood flow to the thalamus region of the brain, HPA axis hypofunction, low levels of serotonin and tryptophan and abnormalities in cytokine function.”

59 Developmental/Etiological Considerations (cont.)
- From the Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS) Association of America, - 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 Nonepileptic Seizures - 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 Darwin’s theory of natural selection to psychological mechanisms - An EP approach to somatization asks whether false illness signaling represents an innate psychological mechanism triggered by situational exigencies - Does somatization represent a behavioral polymorphism that bestows survival value?

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. Put more succinctly, dissociative somatizing patients selectively attend to physical symptoms to the exclusion of other perceptions, particularly when they are under stress. These subjective experiences (pain, sensory loss, fatigue, cognitive dysfunction, etc.) become very "real" and result in “unexplained” symptoms.

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 Anna’s 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. In clinical practice the terms conversion, somatization, and hysteria are often used interchangeably. This fact suggests that clinical practitioners in a number of different areas of medicine and mental health continue to regard early psychodynamic notions of conversion as the essence of somatoform illness. 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. Notably, unconscious conflicts are thought to underlie all manner of neuroses, whether they present as somatoform symptoms, depression, or anxiety. In practical terms, there is broad appeal in psychoanalytic notions about the development of psychopathology, including pathology expressed as somatization.

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-individual basis. It seems likely that somatization, postconcussive syndrome, and maladaptive coping in general likely fit somewhere on the spectrum of early relational trauma. Insights into these matters might well be obtained by examining attachment styles, alexithymia, and affect regulation as a more routine aspect of our clinical assessments.

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 aren’t sensitive enough to pick up on the cognitive dysfunction that exists. Maybe deficits don’t exist (frequently the opinion in the forensic realm).

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, & Gouvier, 1996; Roberts et al., 1990) - Thus, in both clinical and normal samples there is a range of symptom acknowledgement, and normalcy is clearly not an either/or distinction.

90 Neuropsychological Assessment (cont.)
Psychological disturbance in somatization While cognitive correlates of somatization are difficult to characterize conceptually, psychological correlates are well captured by our most familiar measures. MMPI-2 (Butcher et al., 1989). Most commonly used measure of personality and psychopathology in the world. Scale 3 (Hysteria) -- developed to "identify patients who were having hysterical reactions to stress situations" (Graham, 2006) - Effective in identifying individuals who report high levels of specific somatic symptoms including things like chest pain, nausea, and headaches. - Other items involve denial of psychological or emotional problems and naïveté/optimism with regard to how they view others. 60 items comprising Hy in the MMPI-2 were all carried over from the original MMP I.

91 Neuropsychological Assessment (cont.)
Scale 1 (Hypochondriasis) – originally developed to assess preoccupation with the body and disease states. High scorers tend to be characterized as having somatoform disorders (Graham, 2006). RC 1 (Somatic Complaints) – similar to scale 1 and the HEA (health concerns) content scales. Patients with elevations report lots of physical symptoms and are unlikely to see these complaints as having a psychological basis. There is also a greater level of depression and anxiety symptomatology. “Conversion” or somatization V – elevations on scales 1 and 3, with correspondingly lower scale 2. Complaints include pain (head, neck, back, chest), pseudoneurological sx (tremors, numbness, tingling), and vague somatoform sx (fatigue, dizziness, ‘malaise’).

92 Neuropsychological Assessment (cont.)
FBS (Lees-Haley, English & Glenn, 1991) Items selected to be sensitive to exaggeration of personal injury. A reliable and valid indicator of somatic symptom exaggeration in forensic contexts. “…empirical research has established the utility of the scale in identifying potentially exaggerated claims of disability, primarily in the context of forensic neuropsychological evaluations.” In forensic evaluation contexts an elevated FBS score suggests a greater likelihood of exaggeration and/or malingering. Outside this context, elevated FBS scores are less clear.

93 Neuropsychological Assessment (cont.)
Because a patient acknowledges extreme somatoform sx does not, de facto, suggest that they were necessarily doing so for some kind of secondary gain. In summary, the FBS scale might reasonably be thought of as an indication of "somatic distress" not unlike the ‘F’ scale as a more general indicator of distress or "demoralization." We truly are in need of “more studies” in this area, particularly with non-litigating but somatization prone samples, such as… Seemingly with every new journal volume, symptoms validity indices are emerging including more recently - Henry–Heilbronner Index (Henry et al., 2006) - Response Bias Scale (RBS; Gervais, 2005; Gervais et al., in press)

94 Neuropsychological Assessment (cont.)
Clinical caveats… The use of negatively charged labels can be alienating for patients. The use of pejorative labels like "faking" and "malingering" run the risk of prejudicing future providers and might limit treatment potential. This is not to say that symptom exaggeration does not occur and that it should not be labeled as such, but…

95 Neuropsychological Assessment (cont.)
Disorders/syndromes associated with somatization Binder & Campbell (2004) provide a nice review of a number of different FSS with MUS Fibromyalgia, chronic fatigue, and chronic pain Multiple chemical sensitivities/idiopathic environmental intolerances Nonepileptic seizures Postconcussive syndrome following mild traumatic brain injury Multiple sclerosis/autoimmune disorders

96 Neuropsychological Assessment (cont.)
Fibromyalgia, chronic fatigue, and chronic pain Historically, most studies in this area have reported performance deficits on a range of neuropsychological measures involving basic attention/concentration, information processing speed, motor speed and agility, and working memory. Major methodological shortcomings have involved a lack of assessment of effort/motivation. Studies examining symptom validity measures with patients presenting with fibromyalgia, chronic pain, etc, have consistently found an overrepresentation of invalid responding or at the very least, suspect effort (Bianchini, Greve, & Glynn, 2005; Gervais, Green, & Rohling, 2001; Gervais et al., 2002; Rohling et al., 2002).

97 Neuropsychological Assessment (cont.)
Multiple chemical sensitivities/IEI Overall, patients with MCS/IEI tend to show less in the way of significant cognitive impairment as compared to other somatoform disorders and their MMPI-2 clinical scales show a fairly characteristic conversion V. Two recent studies suggest differences in scores on the FBS in litigating samples. Binder, Storzbach, & Salinsky (2006) reported a very high level of FBS elevation while Staudenmayer & Phillips (2007) reported relatively less significant elevation. “…virtuous people without psychological or behavioral difficulties beyond those subsequent to environmental exposure. Their bias is to express stress and distress through somatization by emphasizing physical symptoms and denying psychological symptoms” (p. 67).

98 Neuropsychological Assessment (cont.)
Nonepileptic Seizures (NES) Drane et al., (2006) compared NES and ES groups on a number of measures and included a standardized symptom validity measure, the Word Memory Test (WMT; Green, 2003). Drane et al. (2006) found that over 50% of their NES sample failed the WMT (similar to the limited available data in Binder, Storzbach, and Salinsky, 2006), as compared to only 8% of the ES group. In contrast, Cragar et al. (2006) found that 22% of patients with epilepsy and 24% of patients with NES failed one or more effort measures, while only 11% of a combined NES/ES group did so. …more work to be done

99 Neuropsychological Assessment (cont.)
Postconcussive syndrome (PCS) It is clear that PCS following mild traumatic brain injury (mTBI) is a clinical entity moderated by a number of factors, not the least of which involve premorbid psychological functioning, litigation status, and motivation/effort. In this sense, PCS is much like many other somatic distress disorders. In addition to legitimate cognitive deficits (Binder, Rohling, & Larrabee, 1997; Dikmen et al., 1995; Frencham, Fox, & Maybery, 2005), patients with PCS often complain of a range of vague symptoms such as fatigue, confusion, dizziness, pain, and emotional distress. As such, attention to issues of effort and motivation are impacting our understanding of the cognitive difficulties reported by these patients and have set the standard for such studies in other SD.

100 Neuropsychological Assessment (cont.)
Summary While somatoform symptoms and disorders have been described for hundreds of years, tools for the assessment of the psychological and neuropsychological aspects of these syndromes have only recently evolved to a point where we can accurately capture their essence. Neuropsychological assessment and the insights of neuropsychologists have been particularly helpful in advancing diagnostic accuracy. Like neuroimaging, EEG, and other technologies, current neuropsychological measures are helping to bring somatoform syndromes into a different light, improve conceptualization and treatment, and move us closer to a goal of a less dualistic system of understanding neuropsychiatric illness.

101 Treatment approaches Greater than 45% of all neuropsychologists responding to a recent wide scale survey (Sweet et al., 2002) acknowledged that they did no psychotherapy with patients without brain dysfunction The average amount of time spent engaging in psychotherapy across all respondents and settings, and encompassing patients with and without acquired brain dysfunction, was about seven hours per week (Sweet et al., 2002). This does not necessarily mean seven hours of psychotherapy, but rather seven hours in the provision of these services Thus, despite the fact that the vast majority of neuropsychologists are trained in clinical psychology programs, the nature of neuropsychological practice is such that treatment and psychotherapy are decidedly secondary pursuits (Sweet et al., 2002; Sweet, Nelson, & Moberg, 2006)

102 Treatment approaches (cont.)
Biases about somatizing patients - somatizing patients are lacking in insight and are “brittle” with respect to understanding the essence of their problems - they are poor prospects for psychotherapy, particularly insight-oriented therapies the best that can be done for somatizing patients is to pharmacologically treat symptoms of mood and/or anxiety disorders with the hope that this will provide some general relief Ultimately, somatizing patients are considered difficult to treat because of their lack of willingness to acknowledge the psychological nature of their problems (Graham, 2006).

103 Treatment approaches (cont.)
Therapy approaches - Randomized controlled studies (Allen et al., 2002; Woolfolk & Allen, 2007) with SD are rare. Relevant studies have typically focused on syndromes that do not correspond directly to DSM-based somatoform disorders (i.e. functional somatic syndromes) - Behavioral/cognitive behavioral treatments have been examined with a much greater frequency as these approaches tends to be more regimented and, as a result, easier to incorporate in larger scale studies. Treating Somatization, by Woolfolk and Allen (2007) emphasize the fact many treatment approaches borrow from different theoretical perspectives and integrative approaches seem to work best with SD

104 Treatment approaches (cont.)
Cognitive behavior therapy (CBT) approaches CBT for somatization is based on the idea that patients are troubled by how they think about events and symptoms. The basic goal of CBT for FSS/somatization is to challenge and change the dysfunctional thoughts and behaviors related to a patient’s somatoform symptoms - A small number of reviews have described varied results with CBT in somatoform disorders and FSS (Allen et al., 2002; Kroenke & Swindle, 2000, Tazaki & Landlaw, 2006; Woolfolk & Allen, 2007) CBT seems to enjoy the status of a treatment modality that various professionals see as accessible and reasonable. That is, the ability to specify a certain number of visits, specific content to be covered, and a fairly simple overriding set of principles (identifying and changing dysfunctional cognitions) seems a sensible approach

105 Treatment approaches (cont.)
Cognitive behavior therapy (CBT) approaches Implementation of CBT programs has been a challenge because of the nature of different referral settings. Primary care, gastroenterology, and rheumatology clinics are all likely able to appreciate the benefit of CBT to their patients. Whether they are able to adequately implement such programs is another matter. Going forth, it will be critical to specify the structure and implementation of CBT programs like that described by Woolfolk and Allen (2007). Even given the extremely variable nature of CBT interventions described in the literature over the past 10 years, results are promising.

106 Treatment approaches (cont.)
Psychodynamic approaches Psychodynamically oriented theories about somatization view somatoform symptoms as a means for allowing emotional trauma to be experienced in a less threatening or frightening manner As such, the goals of psychodynamic psychotherapy involve facilitating the understanding of what underlies an individual’s (physical) symptoms Short term dynamic therapy emerged in the 1960s and 1970s as a method for taking advantage of the theoretical richness of ego psychology and attachment theory in a more intense and expeditious manner (Davanloo, 1995; Sifneos, 1987)

107 Treatment approaches (cont.)
- Aside from scattered case studies, there is little compelling empirical work assessing the value of psychodynamic therapy approaches in the treatment of somatization The exceptions have been a number of studies conducted with IBS patients (Creed et al., 2003; Creed et al., 2005; Guthrie et al., 1991; Svedlund et al., 1983) 101 patients were randomly assigned to either a standard medical care group or a group that received 10 hour-long sessions of "dynamically oriented individual psychotherapy" plus medical care (Svedlund, 1983; Svedlund et al., 1983). The psychotherapy treatment group showed significantly less somatic symptomatology both three months and one year post treatment. The difference between groups after one year was greater than it was immediately following treatment, suggesting a strong and lasting effect of therapy

108 Treatment approaches (cont.)
- The psychotherapy treatment group showed significantly less somatic symptomatology both 3 months and 1 year post treatment. The difference between groups after 1 year was greater than immediately following treatment, suggesting a strong and lasting effect of therapy Another group has reported several studies examining dynamically oriented therapy with IBS patients (Guthrie et al., 1991; Creed et al., 2005; Creed et al., 2003), with similar positive results. Treatment included therapy that focused on the relationship between emotions and IBS symptoms, as well as relaxation training and standard medical treatment.

109 Treatment approaches (cont.)
Creed et al., 2003 examined the cost-effectiveness of psychotherapy and paroxetine relative to standard medical care. Healthcare costs in the year following tx were lowest for the psychotherapy group, second lowest for the paroxetine group, and highest for standard medical care. As with the CBT approaches described above, ST dynamic therapy approaches are often used along with ancillary methods involving relaxation, education, and other professionals in different professional contexts. There are considerable benefits to a focused and programmatic approach to working with such patients. The benefits are increasingly being demonstrated in the economic context, which will likely be the prevailing standard in the future.

110 Treatment approaches (cont.)
Integrative approaches The CBT and dynamic therapy treatment studies discussed are integrative. That is, instead of adhering rigidly to a specific psychotherapy model or philosophy, researchers and clinicians are picking and choosing elements of other therapies that are known to improve effectiveness - Psychodynamically oriented treatments are incorporating more structure and time limits as these facilitate improvement in patients given typical treatment environments and constraints. - Similarly, CBT-oriented treatments are incorporating more discussion and processing of emotion and interpersonal content as this important material is often neglected in more structured therapy approaches.

111 Treatment approaches (cont.)
Integrative approaches Interpersonal psychotherapy This approach focuses on problems in interpersonal relationships and how these relate to individuals’ attachment needs It is a “dynamically informed” psychotherapy with a general goal of improving interpersonal relationships and/or changing expectations about those relationships Rather than focusing on specific symptoms or behaviors, IPT emphasizes the importance of relationships and how individuals’ needs are met through them (Stuart, 2006)

112 Treatment approaches (cont.)
In somatization, insecurely attached individuals use physical symptoms to convey their needs to others, often resulting in dysfunctional communication (Stuart & Noyes, 2006). Like short term dynamic therapy, IPT is typically time limited and like CBT, it is manual-based and focused on specific techniques.

113 Treatment approaches (cont.)
Multi-modality approaches Affective cognitive behavioral therapy (ACBT) Affective cognitive behavioral therapy (ACBT) is the moniker given to the treatment program described by Woolfolk & Allen (2007) in their book Treating Somatization: A Cognitive-Behavioral Approach. The book includes a manual for conducting a ten session CBT program, an abbreviated program for progressive muscle relaxation, a symptom severity scale, a somatic symptom questionnaire, and a list of questions to encourage examination of cognitions.

114 Treatment approaches (cont.)
ACBT “Training in emotional awareness and labeling of affect was a component of the original 10-session version of this treatment. We came to believe that, in order to be implemented effectively and used in conjunction with cognitive methods in a comprehensive program of emotional regulation, the emotion focused methods should be expanded and made more central to the treatment. Also, in the 10-session version of the treatment, the various cognitive and behavioral techniques are implemented adequately, but the therapeutic attack on the sick role tends to be preliminary and rather limited, as is the case with our attempts in that format to make patients emotionally self-aware.” (Woolfolk & Allen, 2007, p. 110)

115 Treatment approaches (cont.)
ACBT - Certain therapist characteristics are identified as ideal, and are acknowledged as rare in the experiences of the authors. - Perhaps not surprisingly, therapists with only CBT background tend to struggle with the portions of the program that deal with distinguishing between thoughts and emotions. - The authors suggest that narrowly trained individuals struggle with “emotional nuance” and facilitating patients’ experience of their emotions (Woolfolk & Allen, 2007).

116 Treatment approaches (cont.)
The future of treatment for somatization As recently as 15 to 20 years ago, there was little in the way of an organized presentation of ideas about how to treat patients with functional somatic symptoms (Mayou, Bass, & Sharpe, 1995). The book Treatment of Functional Somatic Symptoms was compiled to provide “a comprehensive account of the treatment of functional somatic symptoms…” This section has reviewed some of this work, but to say that significant advances have been made would be an overstatement. The recent work by Woolfolk and Allen (2007) is a hopeful example of what can be accomplished with a careful analytical approach that is flexible and appreciative of the contributions of many different professionals working with these complex patients.

117 Management All practice settings are different, but I see two fairly distinct presentations where somatizing patients are concerned. Stoic - Typically referred by practitioners from various medical specialties like neurology, rheumatology, infectious disease, and cardiology, but also primary care (family practice, internal medicine) clinics, chiropractic practices, and concerned family members. - These patients appear stoic and matter-of-fact in conveying their concerns, and they emphasize the objective and medical nature of their problems. - It is often the case that there has been an event (an accident or injury) and the patient is simply not functioning at a level that is characteristic of them.

118 Management (cont.) Stoic (cont.)
While it is not universally true, the stoic patient tends to have had less overall contact with the medical system than the expressive patient. rigid and obsessive personality style often quite specific about when their difficulties started “world was turned upside down” and all difficulties follow that event difficult to sort through the reality of such assertions as the stoic patient will have incorporated the historical truth of their experience in a way that makes it unassailable in their mind -In neuropsychology practices, the prototypical example of this presentation is the modal mild TBI case

119 Management (cont.) Stoic (cont.)
The dramatic and almost literary quality of “life changing in an instant” seems to be the main emotional hook for the stoic patient. To the extent that any emotion is shown, it is when discussing the event. “I didn’t ask for this” or “this is not me” are oft-repeated themes that sometimes bring a brief, almost controlled outburst of emotions. Case: Ms. D

120 Management Expressive
- Conform more to what was traditionally described as the hysterical personality style. These patients are characterized by histrionic personality features, depression and anxiety symptoms, hypersensitivity, and dramatic remonstrations with regard to their discomfort. -The "neurotic style" of hysteria offered by Shapiro (1965) is consistent with what had long been described in the psychodynamic literature. That is, hysterical or somatizing patients were prone to histrionics, flamboyance, and a vague cognitive style. Such patients are common in psychiatry and general mental health practices.

121 Management Expressive
- In seeming opposition to the stoic patient, the expressive patient makes it abundantly clear that they are suffering. Their emotions are very near the surface and it is sometimes difficult to get through interviews because of this Digressive, often sidetracked by details Press to get in all the details before they are cut off or redirected “Researchers” and “experts” Intolerant of examiner incompetence & inexperience Case: Mr. M

122 Management The Stoic—Expressive Continuum
Stoic and expressive somatizing presentations could be considered different ontogenetic forms within the somatizing patient. Stoic presentation may be more common in early interactions with the health-care system Prohibitions about personal weakness are still prominent in this stage and there is a general awareness that seeking a doctor's help is a significant acknowledgment of personal weakness The stoic patient may well feel uncomfortable with seeking help in such a direct fashion This does not mean that other forms of help-seeking have not been attempted or even over utilized. In the early stages the somatizing patient may wear out their welcome with loved ones or relatives. They may complain at work or use non prescription medicines excessively

123 Management The Stoic—Expressive Continuum
By the time the patient comes to the attention of the health care system they may feel like they have tried everything in their power to affect some kind of therapeutic change The somatizing patient experiences a sense of liberation that they are going to achieve some relief, or better still, a cure Most of the time, they simply do not. This dynamic is nicely captured in the typical somatization profile on the MMPI-2 When the stoic patient is not "cured" they are often encouraged to seek out another specialist, or referred directly to one. The patient starts to attribute their lack of progress to the incompetence of others or the complexity of their affliction. Providers come to understand in short order that these patients are simply not improving and they may quickly, in the eyes of the patient, change their tune and place blame on the patient for not improving. This change of attitude and approach is very often off-putting to the formerly stoic patient, who can become more dramatic or demanding in their presentation. They come to feel decidedly wronged and they become more vocal in their self-advocacy. Before long, we have a more expressive or demanding presentation and the prospects for successful treatment would seem to be less positive as time passes.

124 Management The Stoic—Expressive Continuum
Providers come to understand in short order that these patients are simply not improving and they may quickly, in the eyes of the patient, change their tune and may blame the patient for not improving. This change of attitude and approach is very often off-putting to the formerly stoic patient, who can become more dramatic or demanding in their presentation. They come to feel decidedly wronged and they become more vocal in their self-advocacy. Before long, we have a more expressive or demanding presentation and the prospects for successful treatment would seem to be less positive as time passes.

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