TREATING SOMATIZATION TREATING SOMATIZATION A Cognitive-Behavioral Approach Robert L. Woolfolk Lesley A. Allen THE GUILFORD PRESS New York London © 2007 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:987654321 LIMITED PHOTOCOPY LICENSE These materials are intended for use only by qualified mental health profes- sionals. The Publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which photocopying permission is specifically granted in a footnote. This license is limited to you, the individ- ual purchaser, for use with your own clients and patients. It does not extend to additional clinicians or practice settings, nor does purchase by an institu- tion constitute a site license. This license does not grant the right to reproduce these materials for resale, redistribution, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, and hand- outs or slides for lectures or workshops). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications. Library of Congress Cataloging-in-Publication Data Woolfolk, Robert L. Treating somatization : a cognitive-behavioral approach / by Robert L. Woolfolk and Lesley A. Allen. p. ; cm. Includes bibliographical references and index. ISBN-10: 1-59385-350-5 ISBN-13: 978-1-59385-350-1 (hardcover : alk. paper) 1. Somatization disorder. 2. Medicine, Psychosomatic. 3. Cognitive therapy. I. Allen, Lesley A. II. Title. [DNLM: 1. Somatoform Disorders—therapy. 2. Cognitive Therapy— methods. WM 170 W913t 2006] RC552.S66W662 2006 616.85′24—dc22 2006012304 To Katie About the Authors Robert L. Woolfolk, PhD, is Professor of Psychology and Philosophy at Rutgers University and Visiting Professor of Psychology at Prince- ton University. He has published many papers and several books on psychotherapy and psychopathology, including Stress, Sanity, and Sur- vival (1978, Monarch) and The Cure of Souls: Science, Values, and Psycho- therapy (1998, Jossey-Bass). A practicing clinician for more than 30 years, Dr. Woolfolk has sought in both his work with patients and his scholarly endeavors to integrate the scientific and humanistic tradi- tions of psychotherapy. Lesley A. Allen, PhD, is a clinical psychologist and Associate Profes- sor of Psychiatry at Robert Wood Johnson Medical School at the Uni- versity of Medicine and Dentistry of New Jersey. She has authored or coauthored numerous journal articles and book chapters on somato- form disorders. Dr. Allen is actively involved in clinical work, teach- ing, and supervising. She is currently Principal Investigator on an ongoing program of clinical research funded by the National Institute of Mental Health. vii Acknowledgments Writing any book entails a variety of struggles that are successful only with the assistance of others. We owe thanks to several peo- ple. Mike Gara provided theoretical and methodological guidance, sound practical judgment, and occasional flashes of brilliance. Paul Lehrer was there at the beginning with his unsurpassed scholarship and estimable clinical wisdom. Javier Escobar’s enlightened adminis- trative leadership and impeccable intellectual sensibilities were indis- pensable to the project. Jim Nageotte of The Guilford Press provided the optimal combination of encouragement and oversight. Thanks also to Seymour Weingarten for being everything a publisher should be. We owe our deepest gratitude, however, to the many patients and trainees who have labored along with us to alleviate the form of suffer- ing that this book addresses. The writing of this book and the research described herein were partially supported by grants from the National Institute of Mental Health (Grant Nos. K08 MH01662, R21 MH066831, R01 MH60265, and P20 MH074634). ix Contents Chapter 1. Introduction 1 Chapter 2. Somatization: Epidemiology, Clinical Characteristics, 14 and Treatment Chapter 3. Affective Cognitive-Behavioral Therapy 46 for Somatization: Rationale and Overview Chapter 4. Assessment 66 Chapter 5. The Context of the Therapy 85 Chapter 6. Behavioral Interventions 95 Chapter 7. Working with Cognitions and Emotions 110 Chapter 8. Interpersonal Methods 130 Chapter 9. Assorted Clinical Topics 140 Overview of Appendices 151 Appendix A. Ten-Session Treatment Manual 153 Appendix B. Clinical Trial Assessing the Efficacy of Affective 165 Cognitive-Behavioral Therapy Appendix C. Severity of Somatic Symptoms Scale 173 Appendix D. Somatic Symptom Questionnaire 179 Appendix E. Instructions for Abbreviated Progressive 187 Muscle Relaxation Appendix F. Examining Thoughts 190 References 191 Index 219 xi TREATING SOMATIZATION CHAPTER 1 Introduction Somatization is among the most puzzling phenomena that health- care workers encounter. In somatization physical symptoms occur in the absence of any identifiable causal mechanism. The causes of somatization that we are able to implicate are neither proximate nor somatic, seeming instead to be indirect and to reside in the patient’s mind or culture. Somatization appears to be universal. We find it in all present societies and in all past societies for which we have relevant records. Forty centuries ago, the physicians of Egypt were familiar with somatization; some years later so were those of ancient Greece. For the contemporary clinician, the patient who somatizes is a pressing practical problem. Here there is distress, dysfunction, and dis- ability of great magnitude and intransigence. Patients diagnosed with the most severe form of somatization, somatization disorder, have been shown to incur healthcare expenses that are nine times the U.S. average and consume disproportionate amounts of the time and energy of healthcare providers (Smith, Monson, & Ray, 1986a). In addi- tion to the extensive direct costs, somatization disorder creates enor- mous indirect costs to the economy in the form of lost work productiv- ity. Individuals diagnosed with somatization disorder report being bedridden for 2–7 days per month (Katon et al., 1991; Smith et al., 1986a). Somatization disorder is not only costly, but also difficult to treat successfully. In a longitudinal study following patients with somatization disorder who were receiving standard medical care, only 31% recovered after 15 years (Coryell & Norten, 1981). Typically, patients with somatization disorder are dissatisfied with the medical services they receive and repeatedly change physicians (Lin et al., 1 2 TREATING SOMATIZATION 1991). These “treatment-resistant” patients frustrate healthcare provid- ers with their frequent complaints and dissatisfaction with treatment (Lin et al., 1991). No controlled medication trial for somatization dis- order has been published. Anecdotal evidence suggests that many patients diagnosed with somatization disorder refuse to take medica- tion and that those who do frequently report adverse medication side effects (Murphy, 1982). The story is much the same with other poly- symptomatic somatoform disorders (Fallon, 2004). As of this writing, pharmacological treatment has had minimal success with somatiza- tion. In this book we describe our efforts to alleviate the suffering of patients with somatization. Over the last decade, we have developed a dedicated psychosocial treatment for somatization that draws upon various traditions in psychotherapy, especially cognitive-behavioral therapy and emotion-focused experiential therapies, a treatment we call affective cognitive-behavioral therapy (ACBT). The principal aim of this book is to describe that treatment and to provide the training material necessary for its effective use. To frame our approach to this problem, we first provide a brief review of the history of somatization and of psychosomatic medicine. We then discuss philosophical and sociocultural underpinnings of somatization and conclude with an overview of theories of somatization. BACKGROUND: HISTORICAL AND THEORETICAL The history of somatization begins with hysteria. Hysteria was first described 4,000 years ago by the Egyptians. Typical cases involved pain in the absence of any injury or pathology in the location of the pain. The Egyptian theory held that a wandering uterus moved about the body and produced pain from various regions. Greek physicians described a similar set of psychosomatic symptoms and essentially retained the Egyptian theory. The Greeks gave us the word hysteria, from the Greek hystera, meaning womb. The Greco-Egyptian formula- tion reveals two noteworthy features: that the disorder was primarily observed in females and that there was something thought to be essen- tially female about the disorder. Although the diagnostic category sub- sumed more than somatization, the term hysteria continued to be widely used to label somatization patients until 30 years ago. Medieval and Renaissance medicine preserved the ancient formu- lation of hysteria as described by the ultimate authorities, Hippocrates and Galen, until the 17th and 18th centuries, when it was first linked with the