Applied Evidence N EW R ESEARCH F INDINGS T HAT A RE C HANGING C LINICAL P RACTICE Somatization: Diagnosing it sooner through emotion-focused interviewing Allan Abbass, MD, FRCPC Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia Practice recommendations somatization, the translation of emotions into somatic problems or complaints. It is well docu- ■ Obvious anxiety in a patient with physical mented—though still largely unrecognized in complaints should prompt an evaluation practice—that somatization accounts for a large for somatization. proportion of office visits to primary care physi- cians as well as specialists,1,2 leading to unnec- ■ Become familiar with the 4 patterns of essary testing, treatment, and hospitalization, somatization and their manifestations. disability and corporate financial loss,3 likely ■ Learn how to conduct an emotion-focused earlier mortality,4 and frustration for patients interview, which, when applied appropriately, and physicians.5 will help rule somatization in or out. No longer a diagnosis of exclusion Despite the burden somatization places on the 42-year-old man has chronic fatigue and medical system, the diagnosis is often made by fibromyalgia that has led to a 13-month indirect methods such as checklist, speculation, A disability leave from work. The reason or exclusion when other problems are ruled out.6 for his current office visit is longstanding pain The common position, even in recent reviews, in his shoulders. As you take his history, he is is that somatization should be treated by non- sitting with hands clenched and he generally specific measures, such as frequent office visits appears tense. to increase the patient’s and physician’s ability to A 38-year-old woman with severe incapacitat- cope with what is often seen to be a chronic and ing gastroesophageal reflux disease, irritable incurable disorder.7–11 Such a position is no longer bowel syndrome, and depression has been too dis- warranted. abled to work for 2 years. At the time of your Based on recent quantitative and extensive interview, her posture is relaxed and she shows case-based research, specific emotion-focused no signs of anxiety. brief therapies and videotape-based research have These 2 very different patients (whose cases clarified how emotions are experienced in the I will review in detail) share a common problem: body and how somatization of emotions occurs (see The physiology of emotions). These meth- Correspondence: Allan Abbass, MD, FRCPC, Associate ods, including short-term dynamic psychotherapy Professor and Director of Education, Psychiatry, Director, (STDP) have been used to diagnose and treat Center for Emotions and Health, 8th Floor, Abbie J. Lane Memorial Building, Halifax, NS B3H 2E2, Canada. E-mail: somatization effectively since the 1980s. [email protected]. Somatization, with its morbidity and chronicity, MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 231 SOMATIZATION need no longer be diagnosed by exclusion nor The physiology of emotions treated palliatively without specific diagnostic testing. To diagnose and manage somatization we ■ THE 4 PATTERNS must know how emotions are experienced OF SOMATIZATION and how they may become somatized. Videotaped case-series research shows 4 main Davanloo discovered through studying sever- patterns of somatization: 1) striated muscle uncon- al hundred case videotapes that specific scious anxiety, 2) smooth muscle tension 3) cogni- emotions manifest in specific ways regardless tive-perceptual disruption, and 4) conversion.18 of gender, age, or ethnicity.12 This emotion Striated muscle tension due to unconscious physiology constitutes a norm to compare anxiety manifests through hand clenching, sigh- with a patient who somatizes emotions. ing, and even hyperventilation that the patient is For example, rage is experienced as an not aware of. These patients may report panic internal energy sensation, heat, or “volcano” attacks, chest pain, headache, fibromyalgia, and that rises from the lower abdomen to the other musculoskeletal complaints. These condi- chest, neck, and finally to the hands with an tions are often frustrating to family, employers, urge to grab and do some form of violence. and physicians since conditions like chronic pain Guilt about rage is experienced with upper respond to treatment slowly or not at all. chest constriction or even pain, intense Smooth muscle tension due to unconscious painful feeling with waves of tears and with anxiety causes acute or chronic spasm of blood ves- thoughts of remorse about experiencing the sels, GI tract, airways, and the bladder. Patients rage.13 When feelings are experienced con- exhibiting smooth muscle tension may present with sciously, by definition they are not being som- GI symptoms, migraine, hypertension, urinary fre- atized at that moment. quency, and upper airway constriction mimicking asthma. They often report histories of depression, Why somatization occurs panic, substance abuse, personality disorders, and When feelings are intense, frightening, or con- past sexual or physical abuse. flicted, they create anxiety and defense mech- Cognitive perceptual disruption due to uncon- anisms to cover the anxiety (see the Figure on scious anxiety typically involves visual blurring, page 234). If these feelings are unconscious to tunnel vision, loss of train of thought, and “drift- the patient, the subsequent anxiety and ing,” wherein the patient is temporarily mentally absent from the room. These patients have defenses may also be outside of awareness. chronically poor memories and concentration. This is the finding common in people who They are commonly victims or perpetrators of have been traumatized by someone close to partner abuse, have frequent accidents, and have them: feelings of rage toward a loved one are transient paranoia. They often end up seeing unacceptable, frightening, and avoided through neurologists and undergoing expensive testing. somatization and other defenses.14 Diverse Most have histories of dissociative disorders, research has found that patients with hyperten- personality disorders, or childhood abuse. In the sion, migraine, irritable bowel syndrome, and family doctor’s office they frequently forget what other conditions internalize anger and thus was said and call back after the appointment. 15–17 increase their somatic problems. Blocking They appear confused and easily flustered and and inhibiting of emotions, including anger, is a either avoid physical examinations entirely or common finding in somatizing patients. endure them with great anxiety. 232 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice SOMATIZATION TABLE 1 Examples of diagnosable somatization patterns Somatization Observations during emotion-focused Examples of related health format diagnostic assessment complaints or health problems Striated muscle Progression from hand clenching, arm Fibromyalgia, headache, muscle tension tension, neck tension, sighing spasm, backache, chest pain, respirations to whole-body tension shortness of breath, abdominal (wall) pain, fatigue Smooth muscle Relative absence of striated muscle Irritable bowel symptoms, abdominal tension tension. Instead activation of smooth pain, nausea, bladder spasm, muscles causes, for example, cramps in bronchospasm, coronary artery the abdomen or heartburn. spasm, hypertension, migraine Cognitive-perceptual Relative absence of striated muscle Visual blurring, blindness, mental disruption tension. Instead patient loses track of confusion, memory loss, dizziness, thoughts, becomes confused, gets weakness, pseudo-seizures, blurry vision paresthesias, fainting, conversion Conversion Relative absence of striated muscle Falling, aphonia, paralysis, tension. Instead patient goes weak weakness in some or all voluntary muscle Conversion manifests as muscle weakness or Major types of defense paralysis in any voluntary muscle. Patients with Two important categories of defense include acute conversion describe dropping items or even isolation of affect and repression. dropping to the floor as muscles give way without Isolation of affect is awareness of emotions in explanation. They will often report histories of one’s head without experiencing them in the body. witnessing or experiencing violent abuse. Intellectualization is a form of isolation of affect. Repression is the unconscious process by One pattern usually predominates which emotions are shunted into the body rather The total amount of somatized emotion is dis- than reaching consciousness at all. For example, tributed over the 4 pathways (Table 1). One strong emotions, including rage, may directly cause pathway generally prevails at any given time, sighing and a panic attack without the person being though different pathways may come into play aware of either the emotion or the sighing.20 as anxiety waxes or wanes. When anxiety is expressed primarily through smooth muscle Experiencing the emotions tension, cognitive perceptual disruption, or con- overcomes somatization version, the striated muscles are relatively Videotaped research also shows that if a person relaxed. can experience true feelings in the moment, This finding of apparent calm while somatiz- somatization of these feelings is weakened and ing has been noted elsewhere in research of overcome. The feelings being experienced push patients with hypertension. This is the “belle out the anxiety and somatization (Figure). Thus, indifference” a patient expresses as they are tem- somatization can be reduced or removed