The Problem of Somatization

 

©1998 by Daniel Bruns, PsyD
All Rights Reserved.

I had a conversation with a physician a while back about psychological conditions which were often present in medical settings. In the course of that conversation, I happened to make the comment that I was an advocate for somatization. At that point, I noticed that there was a sudden lull in the conversation, and the physician was giving me the same look my wife gives me when she feels I ought to be embarrassed. Since that time, I have come to realize that while this notion seems reasonable to me, for many this idea seems to be surprising.

Quite a few years ago, I was teaching a graduate class in Abnormal Psychology. While walking down a hallway of the building, I happened to pass by the student lounge and overheard a conversation between two of my students. These two students were in engaged in a heated discussion about a third student, who I will refer to as "John." While one of the students listened, the other student regaled John in the most explicit of terms. I will not repeat verbatim the expletives used. If one's imagination lags here, I would encourage the reader to spend some time with sailors on shore leave, or perhaps review the Nixon tapes.

Suffice it to say that the person regaling John used every obscenity that I was familiar with. Despite this, the angry student was finding even these words to be insufficient. Finally, in a last explosive burst of utter contempt, the student tersely spit out the words, "John . . . is . . . pathological!!"

It took a few seconds for this to sink in, but I suddenly became aware of something that I found quite extraordinary. This person's vocabulary was stocked with a plethora of graphic obscenities. What struck me was that in the cornucopia of all known vulgarities, the word this person chose as a vulgarity of last resort was a reference to psychopathology.

I have thought a great deal about that conversation. I have come to realize that all too often in our society, psychological diagnoses become curse words. I am convinced that this is an indication of something deep within the psyche of our society, which is a prejudice against mental illness, or against psychological difficulties of any sort. Being a mental health professional doesn't make you immune to this. I found that while my students enjoyed their newfound ability to diagnose others, they felt a deep sense of shame if they thought that any sort of diagnosis could be attached to themselves.

The tendency to use psychological terms as curse words shows a surprising tenacity. For decades, the term "neurosis" was a primary category of psychological diagnosis. In more recent years, however, this term has been largely abandoned. The reason for this was that terms like "neurosis" and "neurotic" had become pejoratives. We came to refer to people that we didn't like as "neurotic," as a means of dismissing the importance or validity of what they were saying.

In a valiant effort to remove these biases, diagnosticians abandoned terms like neurosis and neurotic, and sought instead to create a more neutral set of terms. For example, one new term was "dysfunction." Unfortunately, this effort failed. Now when we want to curse at somebody, we call them "dysfunctional," a term now preferred by many when making derogatory comments.

The same problem occurred with the term "psychosomatic." Originally, it was intended to mean disorders that have both mental (psyche) and physical (soma) components, Unfortunately, it too fell victim to the vulgarization of psychological diagnostic terms. For the average person, psychosomatic means that it is your physical problems are not real, but are rather "all in your head." The psychosomatic person is regarded by many as a neurotic person with ridiculous symptoms who needs to stop acting so crazy and leave the doctors alone. Because of this prejudice, the term "psychosomatic" has fallen into disfavor, and now words like "somatization" and "somatoform" are preferred. These words were initially less value-laden, as nobody knew what they meant. However, as they began to enter our vocabulary, they too have begun to take on negative connotations. As with other psychological diagnostic terms, initially they were technical diagnoses, but eventually they evolved into curse words.

Somatization is one of the oldest of all known psychological diagnoses. The first reference to this kind of phenomena appears about 1900 B.C. in Egyptian documents, and it was also commented upon by the Greeks. In its modern form, it was first defined by Briquet in France in 1859.

As we understand it today, somatization is a phenomena where a person becomes somatically preoccupied. Typically, there are underlying feelings of depression, anxiety or other feelings, which are not recognized or acknowledged by the person. Instead, what the person may be aware of is all the physical correlates of these underlying difficulties. Thus, for example, a somatizer may not recognize that he or she is depressed, but instead may report fatigue. A somatizer may not recognize that he or she is anxious, but may instead report that his or her hands have become tremulous, or that there is a chronic tightness in the back of the neck.

The tendency is to blame the somatizer for the misreport of the symptoms. But in fact, our society fosters somatization. The very fact that psychological difficulties are seen as weaknesses, makes it shameful for a person to admit that he or she has such a problem. Further, if one is seeking help for such disorders, one's insurance policy may well pay for treatment if one's condition is perceived as a medical one, but generally if the same condition is given a psychological diagnosis, one's level of benefits are considerably less. These and other forces at play in our society encourage people to medicalize their psychological difficulties.

As a result of these various pressures, we have the phenomena of somatization. With somatization, persons who are really psychiatric patients end up being seen by the medical system. This ends up being a frustrating experience for all involved. The somatizing patients do not get better, the physicians feel frustrated, and the insurance company is unhappy about paying for treatment which provides little, if any, benefit.

The somatizers are, in essence, round pegs in square holes. I should point out here that when one attempts to hammer a round peg into a square hole, neither the peg nor the hole ends up being very happy about the situation. The same is typically true for somatizing medical patients receiving medical care.

One would think the answer might be simple. Simply refer the medical patient off to a psychologist or psychiatrist. This is easier said than done. Somatizers, as a group, tend to strongly endorse the notion that psychological diagnoses are curse words. Typically, even the suggestion that they may have some sort of psychological condition is regarded by them as slanderous. Having a psychological condition is an indication to them of mental or moral weakness. It is this very aversion to acknowledging any psychological weakness within themselves that produces a blind spot in the perception of somatizers. They fail to appreciate the role that psychological factors play in their condition.

This dilemma has a number of consequences. In terms of patient suffering, persons continue to suffer from somatization and somatoform conditions, as medical treatment generally produces only placebo relief. A patient who is a somatizer is likely to reject the psychological treatment that is needed, and to instead seek medical treatment which is often ineffective. As the treatment they seek is often not what they need, the treatment is more likely to be ineffective. As a result of receiving a good deal of ineffective treatment, they can become frustrated, and this also tends to be associated with a good deal of unnecessary medical expenditures.

From a purely economic standpoint, in the past, people with somatizing disorders generated income for physicians. They frequently had medical complaints, and they kept coming back as their complaints were not getting better. This generated income for physicians. With capitation and managed care, however, these same disorders are now economic liabilities for physicians, as they are under pressure to contain costs. Unfortunately, this is only more likely to intensify the negative feelings already present for people with these sorts of conditions.

Perhaps I can now return to my original point, which is why I am an advocate for somatization. I am not, of course, advocating that people develop somatoform disorders. I am instead advocating that these people get the kind of treatment that they really need.

What I advocate is as follows:

1. I think persons with somatizing disorders need considerable education. They need to understand the kinds of symptoms that disorders like stress, depression and anxiety can produce.
a. Patients need to be made aware of the kinds of symptoms that stress, depression and anxiety can produce.

b. Patients need to be encouraged not to view mental or emotional conditions as being shameful, or an indication of mental or emotional weakness. They are human reactions that everybody experiences.

c. These persons need to be encouraged to seek the best treatment for their condition.

2. I also think that physicians could benefit from additional education in recognizing somatoform disorders.
a. All too often, a person appearing in the emergency room stress-related chest pains is given only a negative diagnosis, such as "You're not having a heart attack."

b. A positive diagnosis such as "you are having a panic attack" commonly is not made. Unfortunately, all too often, such patients simply get dismissed, while depressive, anxious and other psychological conditions go untreated.

c. When physicians do make referrals for mental health treatment, it is important to do so in a supportive and non accusatory manner. All too often, patients will perceive such a referral as rejection and a negative moral judgment by the physician. Such patients may feel embarrassed about pursuing further care, and in the future may be more reluctant to report such symptoms to their doctor.

d. Physicians need to prepare themselves to discuss the mind-body connection with their patients. The mind and body have a remarkable interrelationship which is difficult to understand. What is clear though, is that adopting a holistic treatment model offers great benefits.

3. Somatization and somatoform disorders are best treated by a collaboration of medical and mental health professionals. Physicians are able to rule out medical conditions, but have more difficulty identifying the psychological dynamics underlying somatization. On the other hand, psychologists have developed technology in the form of psychometric measures that can assist in the assessment of somatoform tendencies, but are not able to rule out possible organic contributors to these conditions. It would seem that physicians and psychologists would be natural partners in this enterprise.

4. On a broader scale, I think educating the public about the physical impact of stress and the role of psychological factors in medical conditions in general can be beneficial with regard to increasing public acceptance of such disorders. Removing the social stigma would make it easier for people to admit to the underlying difficulties that they are suffering from

5. On the legislative level, it would be beneficial if there were a parity between insurance benefits for medical and emotional disorders. It is not uncommon to find that an insurance policy will pay for treatment if one is diagnosed as having chronic fatigue, but considerably fewer benefits will be available if one is diagnosed with depression. This creates a societal pressure for persons to medicalize their psychological difficulties.

6. In Zen meditation, persons are often invited to meditate on impossible ideas, such as the sound of one hand clapping. For those who can master that, I offer a new challenge: Try to imagine yourself saying "somatization" without cussing.

 

 

Reader Responses

 

Dear Dr. Bruns-- My strongest praises to you on writing an article regarding somitization! I could relate very well to many of the ideas you listed. It's nice to know I have an "advocate." I found your web site while doing a search on conversion disorder. I have been suffering from this disorder since 1992, but had a hard time accepting that I my problems were psychological and not physical. I am curious to know if you have dealt with other patients who have conversion disorder, which is commonly classified as a somatoform disorder. I have found two other people on the Web who have the disorder, and we E-mail back and forth on a regular basis.

We would love to start a support group for those who suffer from conversion disorder, but our search has been very difficult. We know that it is a rare disorder (or possibly a common "hidden in the closet" disorder which people are afraid to admit or talk about openly). I am aware that due to doctor patient confidentiality, you would be unable to provide me with a list of those having this disorder. But I am asking you to give my E-mail address to patients who have the disorder, and to encourage them to write to me. Any help you (or your colleagues) could give me would be most appreciated. My E-mail address is: xxxxxxxxxxx, and my first name is J. I sincerely thank you for your efforts, and am glad to have found a doctor who understood the implications of the disorder. Keep up the good work! Sincerely, -J. M.

P.S. Are you aware of any publications on this disorder? I know it is also referred to as hysteria. I have placed an order for "The Analysis of Hysteria" by Harold Merskey. I should receive it in about 6 weeks. Please advise me of any other publications you are aware of. Again, I thank you kindly for your help.

 


Dear Dr. Bruns, Thanks for your article on somatization. I have conversion disorder and I always hated when I read about conversion and somatization being linked together. I have a different and better understanding now. Jill told me about your article. My conversion started after a severe infection in 1991. I had no control over any of my voluntary muscles.

After all tests coming back negative, I thought my immune system had attacked my nervous system and the wrong messages were being sent from the brain. I thought it would go away in time. A psychiatrist talked to me and told me I sounded like a smart cookie. I was 39 years old at the time and majoring in applied math at a local university. I was admitted to a University Hospital within 5 days of coming home from the first hospital. The neurologist knew it was conversion at the time. He just told me it was from stress. Being a woman I thought he meant it was all in my head. He never explained to me about conversion disorder. I did not accept the diagnosis until 1993. I was completely disabled by this time.

I am very thankful that I had understanding doctors. I never had any horror stories about doctors. I did not hear the word conversion until I asked. They just kept telling me stress. I slowly started to get better after that. I regularly see a psychologist and psychiatrist. I have been trying to find case studies of patients with conversion disorder with no luck. I want to know how they were treated, the severity of their disorder and how they responded to treatment. Also my psychiatrist told me that 50% recover in 4 to 10 years from acceptance. He tells me I am the most severe case that he has seen at the University. He keeps telling me I am a success story. I am diagnosed with the conversion being secondary to masked depression. Is it usual for conversion to be secondary to something else?

I would also like my E-Mail address given to other conversion patients xxxxxxxxxxxxxxx. Anybody reading this that is fighting the diagnosis of conversion, don't! With treatment, it will get better and it is not nearly as bad as some of the neurological diseases it can mimick. I think of the brain as a very complex organ of the body just as any other organ. Psychiatrist treat disorders of the brain and psychologist are like going to physical therapy for other problems. Thanks, S

 

S - Thank you so much for telling your story. A lot of the information in this site is somewhat theoretical, so it is extremely helpful to have the actual experiences of patients here for others to read. I really believe that it will help professionals and the public to better understand the experiences of people like yourself.

I have recently been rereading the book "Timeless Healing" by Herbert Benson, MD. Dr. Benson is from the Harvard Medical School, and is an extremely well-respected authority on the mind-body connection, and you may find his thoughts helpful. It has been my experience that with the right kind of treatment, persons like yourself have a very good chance recovery.

Take Care,

Daniel Bruns, PsyD

 


OK all you phycologists, here's some practice... Supposedly, I'm a "tough guy" 6ft 3" 200lbs I practice several martial arts, lots of sports, motorcycle racing, no problem with rollercoasters, heights etc. Yesterday I has a date with my dentist to get one wisdom tooth pulled. I've been there 4 x now and each time, I bolt from the chair! Yesterday they gave me Nitrios for about 15 minutes, spray froze my mouth but when they propped my mouth open. I blew! I was out'ta there. (Istill had to pay them $85.00 for the nitros & consultation). Today Iam very depressed. I diden't think it would effect me like this but I don't feel like doing anything. I also sprained a wrist in Martail Arts and so I feel like I was good at that but no more. I can't even bring myself to the class becasuse I feel like a failure. I coulden't even wear my combat outfit around the house because I don't feel worthy of it. My business also suffers and I have had to resort to living with my parents. Not easy with a wife and child. My father tells me I have changed and favours my older brother who in my opinion, has nothing to favour about. What do you suggest? P

 

 

P. -- Helping people with difficulties like yourself is the type of thing we do every day. First of all, let me say that the purpose of this site is not to provide psychological or medical services, but rather to provide information. I would encourage you to seek answers to your problems through local psychologists or physicians. Having said that, it sounds like you had a difficult time at the dentist's office. Many people have difficulty tolerating the stress of medical or dental procedures. Many people feel claustrophobia in MRIs, fear anesthesia or needles, or may feel humiliated, embarrassed or violated by a procedure. You aren't alone. The important thing to know is that there are things that can be done to help. It sounds like you may have a very anxious reaction to dentists. The first step would be to talk to a physician or psychologist about this, and to have this evaluated. Your physician may prescribe something to help you with this difficulty, and get you through this procedure if you need it. Additionally, your psychologist could help you to address your reaction, and help you develop special mental strategies to keep this from beating you. It would be especially helpful if they would communicate their plan with your dentist. Your feelings of frustration and depression following your wrist injury are understandable. I can say that most people have a difficult time following an injury. Based on a national sample of injured patients in the US, we found that the average patient showed signs of depression and anxiety on the BHI. Further, people who are very invested in their health and fitness like yourself may feel a greater sense of loss. Again there are a variety of things that can be done here to help you as well. Part of these are things that your health caregivers can help you with, while part are things that you will need to do for yourself. Working as a team together with your caregivers, I believe that you can make great improvements to your situation.

Good luck.

Daniel Bruns, PsyD

 


Dear Dr. Bruns:

I have been an internist in practice for 20 years, currently in xxxxxxxxx. As you already know, some of my most difficult referrals are patients with somatoform disorders. Usually, I am their 40 or 50t physician. They have had countless tests, pokings and prodings not to mention surgeries, scans, and other unnecessary torture. They have ALL been treated with benzodiazapines, narcotics, and antidepressants at t he very least. Never, never in 20 years have I met such a patient who has been informed that they have a "somatoform disorder."

I believe that one of the reasons they are so difficult to deal with is that they are not allowed to know what their diagnosis is or to learn anything about it. The only meaningful positive thing we have to offer our patients is insight and we usually fail at doing that. I have done a cursory web search to see what patients can learn about somatization and what sort of "peer" support there might be. I found one site urging patients to come in and have a 24 hour esophageal pH monitoring since "bile reflux is the most common cause of panic and somatic disorders."

Great! ... more useless tests.

At least your message on the web is encouraging. I usually explain the disorder to my patients in terms of a hightened neurologic sensitivity with real physical outcomes. Most people are comfortable with the idea of mental factors interacting with "real" physical illness... such as stress precipitating a heart attack. What I can do in a few office sittings is... well, not a whole lot.

I thought you might know what support systems are available for patients with somatoform disorders such as self-help literature, support groups, medical literature, etc. Everyone else has a group... AIDS patients, fibromyalgia, chronic fatigue, etc,etc. Or perhaps the diagnosis is so distasteful they don't even want to talk to each other.

Dr. TM

 

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