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Editors: Gabbard, Glen O.; Beck, Judith S.

; Holmes, Jeremy Title: Oxford Textbook of Psychotherapy, 1st Edition Copyright 2005 Oxford University Press
> Tabl e of Contents > Secti on II - Psychotherapy in psychi atri c disorders > 20 Psychotherapy of somatoform disorders

studies and attempts at classification that have been beset with uncertain treatments for uncertain disor ders. But there are new advances appearing on the horizon. This chapter revie ws what is known about the psychotherapeutic

confusion, controversy, an d inconsistency, we are left confronted with

interventions that have su cceeded or failed with these disorders and the challenges they present to healthcare professionals. Matters of diagn osis, clin ical descr iption, prevalence, and etiology are covered sufficiently in other texts and will be touched on on ly briefly here. Similar ly, detailed e lements of psychopharmacotherapy remain be yond the scope of th is chapter. Our focus will be on key practice pr inciples of psychosocial treatments of the entire group of somatoform disorders. Each disorder will be discu ssed in terms of un ique therapeutic requirements or specific pe rtinent research, concludin g with a general therapeutic for mulation appropriate to the entire group.

20 Psychotherapy of somatoform disorders


Don R. Lipsitt Javier Escobar Since medicine's earliest beginnin gs, physician s have been perplexed and vexed by patients wh ose symptoms seem medically unexplainable and who respond poorly to treatment. In 1927, the legendary Francis W. Peabody, Harvard Professor of Medicine at Boston C ity Hospital, wrote that teachers and students are at risk of seriou s error in their attitude toward a large group of patients who do not show objective, organic pathologic conditions, and who are generally spoken of as having nothing the matter with them (Peabody, 1927). Peabody identifies these patients as having conditions under th e broad heading of psychoneuroses, with the ultimate causes to be fou nd, not in an y gross structural changes in the organs involved, but r ather in nervous influences emanating from the emotional and inte llectual life wh ich, directly or indirectly, affect in one way or another organs that are under either voluntary or involun tary control (Peabody, 1927, p. 878). Treatment, he said, is most appreciably the responsibility of the internist and general practitioner, and its effectiveness is most attributable to the quality of a car ing patientdoctor relationship. He is most famously quoted for his concluding statement th at the secret of the care of the patient is in caring for the patient (Peabody, 1927, p. 882). How far have we come regarding diagnosis and treatment of these difficu lt patients since th ese perceptive words were written? Because organized medicine has had little success with these patients and perhaps because of the pr ickly relationsh ips they have with their physicians, understanding of the ir illness behavior, diagnosis, an d treatment have, over the years, moved from medicine into psych iatry's domain under the current rubric of somatoform disor ders, disorders that present in the form of physical distress but are believed to have a significant emotional (psychological) dimension. The treatment literature consists largely of cumu lative experience and clin ical wisdom but disappointingly fe w reliable we ll-controlled studies. With few research

Conceptu al iz ation
Detailed inspection of functional somatic syndromes r eveals that all include common ele ments.

No gold standard to confir m or rule out the diagnosis. Presence of multiple unexplained symptoms originatin g in several organ systems. High leve ls of psych iatric comorbidity. No clear pathophysiology; while a number of pathoph ysiological mechanisms have been invoked to explain many of these syndromes (e.g., symptom amplification, muscle contraction, catecholamine release, persistent neurobiological dysfunction, neurological hyperreactivity, e levated cortisol) no cle ar pathophysiological knowledge has emerged for an y of them.

No consistent explanation emanating from ph ysical an d laboratory assessments. No good fit with ru les of allopathic medicine. Comparable responses with certain psychological [e.g., cogn itive-behavior therapy (CBT)] and phar macological (e.g., antidepressants) interventions.

The presence of emotionally charged, highly politicize d groups of patients/advocates. Indeed, patients with functional somatic syndromes su ch as chron ic fatigue, fibromyalgia, an d in general, man y of those wh o prefer other medicalized labe ls

such as Lyme disease, or environmental disorders, h ave been forming highly passionate groups.

Another body of research, particu lar ly with in the last 5 years, has examined the efficacy of CBT for somatization. Accor ding to the research, CBT seems to he lp patients modify thou ghts and behaviors

Rese arch
In 1991 excellent reviews of th is topic appeared almost simultaneously on both sides of the Atlantic (Barsky and Borus, 1999; Wesse ly et al., 1999). These reviews underlined the man y common epide miological, clin ical, and psych opathological aspects of these functional syndromes in efforts to set the stage for much -needed collaborative research in this area. Barring more con vincing re search evidence, it is ultimately one's personal defin ition of somatization that influences the selection of treatment: thus, therapists favoring the concept of a learned dysfunction may prefer cognitive-behavioral approaches wh ile those theorizing a deve lopmental failure in mothering, for e xample, may prefer more dynamic and su pportive techniques, and so on. While descr iptive accounts of somatization abound, th eoretical or causal explanations are scarce. In this context, and despite its dualism, we find the developmental sche ma of Max Schur (a psychoanalyst and Freud's personal physician) appealing as a we ll-rounded theory supported by experience. Schur (1955) posited that the infant is born with a capacity for on ly undifferentiated physical expression and it is not until the development of motor control, neural structures, and language (ego development) that the ch ild has the capacity for direct emotional expression. According to Schur, the ch ild passes from a totally somatized state to one that is gradually de-somatized. In the face of trauma, depr ivation, developmental failure, and other debilitating factors, the child may revert (regress) to re-somatizing states. Henceforth, somatization may be resorted to for the expr ession of unspeakable emotional distress. Such a theory has some endorsement from studies that have shown a high correlation between medically unexplained symptoms and ear ly childhood sexual and/or ph ysical abuse (E. A. Walker et al., 1999; Newman et al., 2000). It is also supported by findings that suggest a correlation between physical symptom reporting P.248 and alexith ymia (S ifneos, 1973). Further theoretical e laboration by Scheidt and Waller (1999) emphasizes the importance of the quality of early maternal attach ment in determin ing later (adult) predisposition to somatization.

that are associated with somatization and recogn ize the role of stress in ph ysical dysfunctions, such as sleep disturbance, fatigue, pain, and so on. Patients are subsequently helped to combat this effect via numerous behavioral techn iques, including re laxation trainin g and graded increases in activities. From a cogn itive perspective, CBT he lps these patients identify thoughts that contr ibute to in creased stress, inactivity, and health concern. Often, these patients think catastrophically about the ir physical symptoms, leadin g to conclusion s that one is sick and that one must limit physical activity, contributing to a cycle that perpetuates the somatic process. A number of studies support the use of CBT for patients suffering from somatization. A llen and associates (A llen et al., 2001) showed that CBT helped patients with fu ll DSM (Diagn ostic and statistical manual of mental disorders) somatization disorder (SD) significantly reduce their physical discomfort, anxiety, and depression, as well as increase their physical function ing. Other in vestigators have condu cted CBT in the primary care setting with patients presenting unexplained physical symptoms (Lidbeck, 1997; McLeod et al., 1997; Sumathipala et al., 2000). These studies have demonstrated reductions not on ly in physical and emotional symptoms, but also in physical impair ments and medical utilization. Although CBT has been typically admin istered in mental health specialty settings, there seem to be a number of advantages to providing CBT in primary care, when workin g with somatizing patients. First, because these patients preferentially use medical services, providing CBT in primary care helps to match treatment to the somatizing patients expectation s; somatizing patients are apt to fee l mor e comfortable in the primar y care environ ment. Second, patients suffe ring from medically unexplained symptoms ofte n receive signals from othe rs that their symptoms are less than ge nuine. For this reason, referral to mental health settings often con veys more stigma, and the pe rception that referral to a mental health facility invalidates their physical distress by suggestin g that it is all in their heads. As a result, patients often do not follow through with me ntal health referral and frequently switch physicians (Lipsitt, 1964; Lipsitt, 1968; Lin et al., 1991). Moreover, providing CBT in the primary care setting has the obvious benefit of maximizing coordination be tween the mental health pr ovider and the primary care physician.

As almost all individuals experience one or an other physical symptom in a period of a week or two (Kellner and Sheffie ld, 1973; Pennebaker et al., 1977) it shou ld be obvious that it is on ly when such symptoms exceed a threshold pr ompting medical help-seeking th at the labe l somatization is typically warranted. It is the primary care physician, not the psych iatr ist, who most often sees patients with somatizing conditions. Moreover, the mu ltiple defin itions for these syndr omes that e xist in psychiatry and medicine, make prevalence data very difficult to gather, and the frequent changes in the nomenclatures add to the confu sion. Because most somatofor m disorders are seen in outpatient practices, little is kn own about the prevalence of somatofor m disorders in the general or psych iatr ic hospital. And because patients with somatizing conditions do not u sually identify themse lves as having psych iatric illness and will common ly reject referral to a psychiatrist if it is offered, the prevalence in psych iatr ic practice is probably less than in pr imar y care. In medical practice, somatization is tied to the issue of the frequent consu lters. These patients present with symptoms th at change over time. They receive more medical diagnoses, have unh ealthy lifestyles (in terms of diet and use of alcohol and tobacco), and a high frequency of mental disorders (over 50% reported psychological distress). However, despite the ir h igh leve ls of psychological symptoms th ese patients are very unlikely to see themselves as psych iatric patients, even though about one-fourth of them meet diagnostic cr iteria for major depression, 22% for anxiety disorders, 17% for dysthymia, and up to 20% for full DSM criter ia for SD (Gill an d Sharpe, 1999). Although little is understood about the precise way in which the somatization process is mediated, some have suggested a central nervous system e laboration of stimu li, with amplified perception (Barsky, 1992). Others have posited some kind of physiological reactivity or h ypersensitivity (Miller, 1984; Sharpe and Bass, 1992; Rief and Auer, 2001). James and associates (James et al., 1989) suggest that attentional processes of somatizing patients are affected by some fundamental neuronal and physical dysfunction. EEG studies showed that somatizers responded to both relevant and irrele vant stimu li in the same way, suggesting that some filter mechanism may be missin g, making it difficu lt or impossible for the somatizer to ignore irre levant stimu li. Psychological studies have demonstrated th is blockin g action to occur more often in individuals who have e ither high or low hypnotizability as well as h igh scores on the Marlowe-Crowne Social Desirability Scale (Wickramasekera, 1998). PET scan studies (Garcia Campayo et al., 2001) have sh own changes in somatizing patients that resemble those

found in depressed patients. Other studies suggest th at biological and pathophysiological changes may contribute to somatizing conditions (Fink et al., 2002).

In spite of the ir shared characteristics, each somatoform disorder shows variations in h istor y, conce ptualization, and treatment as described separately below. Pain disorder will be omitted as the psychotherapy of these patients is comprehensively discussed in Chapter 33 (Medical patients).

Somatiz at ion di sor der


SD has been defined as a complex, usually chron ic condition primar ily of females with a h istor y of multiple unintentionally produced physical complaints beginn ing at a young age and always before 30. Briquet's virtual encyclopedia of physical symptoms was reduced in DSM-III to 14 physical symptoms for women and 12 for men of a possible 37 to reach diagn ostic threshold (qu ite arbitrar ily, some have said), changed in DSM-IIIR to 13 total, and finally, in DSM-IV, modified to e ight ph ysical complaints referable to fou r pain sites or functions (e .g., back, chest, urination), two nonpain gastrointestinal symptoms (e.g., nausea, bloating), one nonpain sexual or reproductive syste m symptom (e.g., menstrual irregu larity, loss of libido), and one pseudoneurological symptom (e.g., ur inary retention, aphon ia, blindness). Although symptoms are unaccounted for by known general organic pathology or substance abuse, they may nevertheless be exaggerations of ordinarily expected symptoms of coexisting physical disease. Symptoms generally occur over a per iod of seve ral years accompanied by sign ificant impairment of social and occupational function and h igh utilization of medical resources, usually resulting in e ither ineffective and/or unnecessary medical/surgical treatments. Many encou nters of these patients with physicians generally evoke frustration in both parties of the relationsh ip. Several researchers, responding to an e xpressed need for a diagnosis of subtypes seen in pr imary care in the range between full-fledged SD and the undifferentiated for m, have offered suggestions of somatization syndrome, abridged SD (Escobar et al., 1989), polymorphous, multisomatofor m (Kroenke et al., 1997), or polysomatoform (Rief and Hiller, 1999) disorder. Because of the difficu lty in applying the unwie ldy diagn ostic criter ia in primary care practice, Escobar et al. (1989) devised an abr idged somatization construct, called a S omatic Symptom Index (SSI), requir ing only four symptoms for males and six for females to reach diagnostic significance. When the fu ll cr iteria are not met for SD, patients with mu ltiple unexplained somatic complaints lasting at least 6 months are usually given the diagnosis undifferentiated

somatofor m disorder. Th is classification may include such entities as fibromyalgia, irr itable bowel syndrome, chron ic fatigu e syndrome, and others. DSM-IV criter ia were designed pr imar ily for adult popu lations, but may have applicability to ch ild and adolescent patients.

shown a 60% comorbidity with medical disease, 5594% with

depression, 2645% with panic disorder, and 1731% with alcohol abuse or dependence in SD patients (Bass and Murphy, 1991); and there is a relatively h igh rate of personality disorder in patients with SD, the most frequent types be ing avoidant, paranoid, and se lf-defeating, not borderline or h istrionic as previou s observers have re ported (Rost et al., 1992). Counteracting the prevailin g rather nih ilistic attitude about treatment of SD, one study showed impr ovement over a per iod of 2 years in 30 patients treated in an inpatient psychosomatic hospital in Germany (Rief et al., 1995); treatment utilized an integrative behavioral medicine approach con sisting of individual psychotherapy, asse rtiveness train ing, problem-solving train ing, progressive muscle re laxation, and other cogn itive-behavioral, emotional an d move ment therapies. Patients showing most improvement had fe wer symptoms and less psych iatric comorbidity. It is generally acknowledge d that to treat effectively patients with SD, primary physicians mu st be recruited as participants. A groundbreaking controlled study by Smith et al. (1986) demonstrated the effectiveness of a consu ltation letter to primary physicians instructing them on a fe w key management techniques to u se with the ir patients. Although patients did not show great change diagnostically or symptomatically, they did improve in function, decreased their overutilization of resources and generated significant cost-savings. While n o adequately controlled studies of psych otherapeutic intervention existed pr ior to the study by Smith and colleagues, a number of studies of undifferentiated forms of somatofor m disorder suggest therapeutic benefits from an accepting attitude in the therapist (Rost et al., 1994), cautious efforts to sh ift the patient's attention from somatic to emotional features (Morriss and Gask, 2002), or the use of groups that focus on explanation, support, relaxation, and cogn itive-behavioral approaches to emphasize adaptation to chronic somatic distress (Ford and Long, 1977; Melson and Rynearson, 1986; Hellman et al., 1990; Kaplan et al., 1993; Guthr ie et al., 1993; Payne and B lanchard, 1995; Speckens et al., 1995). More recently, brief psychodynamic therapy of unexplained somatic symptoms proved super ior in both controlled randomized and uncontrolled studies (Nielsen et al., 1988) compared with regular medical treatment alone. An uncontrolle d intensive inpatient treatment program for chron ic severe somatizin g patients described a 33% improvement rate in 92 patients treated with combination s of re laxation training, ph ysical activation, and pharmacotherapy (Shorter et al., 1992).

Conceptu al iz ation
Freud's first patients were somatizers. As a clin ical ne urologist beginn ing practice, h is patients comprised essentially other physicians failures, n ot dissimilar to what is e xperienced by new young physicians today. H is meticu lou s study P.249 of h is patients symptoms and histor ies cu lminated in his theories of psychoanalysis, the sign ificance of symptoms as derivatives of early life experience and even the concept of negative therapeutic reaction in which patients resist symptomatic improvement. Freud's famous descriptions of h is earliest hysterical patients might well be considered to have SD if seen today. While a specific etiology is unknown, the origins of SD share many features with other somatoform disorders. Some have suggested that patients with SD have an intensified sensitivity to normal physiologic events and may also exhibit masked depression in response to trauma, loss, depr ivation, and rejection. Various descr iptions of SD rely on psychodynamic pr in ciples to understand the symptom pr ofile and the behavior of patients so diagn osed. Treatment may depend upon whether that conceptualization focuses on de velopmental failure, disturbances in the infantmother or infantcaretaker relationsh ip, affective deficits, alexithymia, object relations problems, homeostasis disruption, se lective ly learned dysfunction, or fau lty developmental regulation (Knapp, 1989). Emphasis on learned behaviors may lead more commonly to cogn itivebehavioral or grou p interventions, wh ile other conceptualizations may encourage more relational, interpersonal, or psychodynamic approaches. Psychopharmacological approaches may be in dependent or combined with other interventions. No preferred treatment has been established for SD. A search of the Cochrane Library databases for research into the psychotherapy of SD reveals no relevant findings. Most researchers in dicate that the best therapeutic ach ievements, as modest as they may be, are the result of an ongoing e mpath ic re lationship with a consistent caregiver. Research on interventions with SD patients is hampered by a variety of problems: patients are usually seen in primary care settin gs, wh ere therapists may be poor ly prepared to work with de manding, frustratin g patients; comorbid physical disease often is a major con founde r. Studies have

Key p ractic e pr inc i ples


SD embodies virtually all the characteristics that make somatizing patients very refractory to attempts at therapeutic intervention: multiplicity of symptoms; chronicity; imperviousness to traditional types of reassurance; r igidity of adherence to belief in the presence of physical disease; h igh and usually inappropr iate utilization of medical resources; unresponsivene ss to pharmacologic treatment trials; alexithymia; r isk of occu lt comorbidities; sensitivity to rejection ; and frequent dysfunctional patientphysician relationsh ips. Such a context represents a profound challenge to the most well-inte ntioned, dedicated physician. With th is realization, first attempts at establish ing a therapeutic setting mu st begin with a caring rather than curing orientation, one that conve ys acceptance, sincer ity, and flexibility to the patient. Therapeutic triumph s may be measured in reduced overutilization of resources, limitations on u nrealistic expectation s, a commitment to a single primary care physician, and min imalization of furor therapeuticus that may result in useless procedures, tests, and surgeries. The ph ysician must be prepared for a long-term commitment to patients with SD. Restraint must be exercised in th e urge to refer for specialist consultation, unless there is reasonable evidence to suggest specific comorbid condition s and thorou gh preparation of the patient for such referral. Wishfu l expe ctations in fin din gs and outcome shou ld be curtailed and the patient must be assured of the continuing interest of and appointments with the primary physician. Helping patients to correct distortions about symptom relevance and meaning or to perceive somatic distress as a common response to life stresses may be a slow pr otracted process that, if pushed too abruptly, may mistakenly convey to the patient the physician's distrust, disbe lief, or outr ight rejection of the patient's complaints. Families of patients with SD common ly have already registered disbe lie f in the patient's illness, pe rhaps even accusing them of malinger ing; the advocacy of the ph ysician in such circu mstances becomes an even more essential ingredient for management. Some of the ele ments of C BT may be incor porated conveniently into the primary care physician's treatment strategy. For example, diary-keeping by the patient, activity pre scriptions such as exercise and yoga, an d ancillary somatic treatme nts such as acupuncture, r elaxation, meditation, massage, and so on are more easily accepted by these somatizing patients than attempts at mental recommendations. When SD patients request medications, as they frequently do, it is necessary to review the patient's (usually) previous negative experience, the

failure of medications to offer relief, and the var iety of side-e ffects that usually accompan y tr ials of any new drug. Adher ing to the low- or nodrug treatment approach may be difficu lt for the physician, but in time can demon strate to the patient greater interest in the patient herse lf, with a deflection of exclusive focus on the symptom(s) alone. The presence of well-defined comorbid states su ch as anxiety, depression, panic disorder, or psychosis may, of course, call for the judicious prescription of specifically targeted pharmacologic agents. In time, the physician and patient may both be rewarded with a dampened organ recital, decreased agitation, improved functional capacity, and more appropr iate, beneficial and less costly use of health resources.

Case ex am ple s Case 1


The following case vignette illustrates a supportive, psychodynamic approach. Mrs N's first visit as a new patient to a medical clin ic was at the age of 45 with a complaint of var icose ve ins, 4 years after a hysterectomy in another hospital, where she had been seen for many ye ars with mu ltiple physical complaints. In th is first visit she revealed that her husband had died 2 years before her hysterectomy and her P.250 father died of a stroke at age 72 several months before her visit to the new clinic. In the next 12 years she had had surgery for hemorrhoids, varicose ve ins, adhesions, and scar reconstruction. Her medical record noted many visits to specialty clinics as we ll as the emergency room for a variety of major and minor complaints. In Skin Clinic alone, she was treated for ecze ma, varicose dermatitis, fibrous polyp of the vu lva, contact dermatitis of the ears, seborrheic dermatitis, and contact neurodermatitis. S he had had several minor accidents, dental proble ms and repeatedly lost her eyeglasses. It was not until 12 years later that emotional difficulty

was n oted in her chart when she was seen in Neurology Clin ic with intense pain that cou ld not be accounted for on th e basis of her vascu lar disease. However , she was returned to Medical C linic where she complained excessive ly of joint pain thought by her doctor to be out of proportion to ph ysical findings. Finally, an entry of neurasthenia was made in the record an d she was referred for psych iatr ic e valuation. At fir st reluctant to see the psych iatrist, she ultimately accepted and in addition to current complaints she said that sh e had been sick all my life but that thin gs had gotten worse after her father died. She was n ow experiencing fatigue, abdominal and chest pain, and difficu lty sleeping. She said she can usually take things on the chin and come up fighting, but th ings had be come more than she cou ld handle. Accustomed to doing things for others, she found satisfaction in work as a saleslady, although she had stopped working because of her ailments. Other doctors, she said, had tr ied many drugs but they e ither did not he lp or she developed side-effects. Complainin g of her pr ior tr eatment, she said that she cou ld take better care of herse lf than some doctors could. A plan was presented to see Mrs N once a month for a half hour. Because many medications had already failed to help her, a decision was made not to prescribe anything, but rather to appeal to her inherent strength to help herself. She was praised for her strength and her ability to come up figh ting. Her organ recital was listened to patiently and frequently (a major aspect of each session) with the reassurance that these things had bothered her for a long time and that it surely must have been frustrating, as was the failure of previous treatme nts to he lp; the physician expressed h is awe that she was

able to survive all these stresses and strains and still be able to manage. She was informed that her symptoms might, in fact, not get better, althou gh sh e may be able to fight them to some degree. Because she always fe lt better doing for others rather than for herself, she was encouraged to resume her work as a saleslady and found satisfaction and distraction in that endeavor. Furthermore, because she said she was sympathetic with those wh o are unhappy an d neglected, she was advised also to offer parttime volunteer wor k in a neighborhood nursing home, work that sh e found very satisfying (masochistic characteristics of her personality were constructively satisfied). Although symptoms did not remit, in time she reduced her visits to specialty clin ics, discontinued her use of the emergency room, and began to talk more about her family relationships than her ph ysical complaints. In time (that is, 2 years or a total of 24 halfhour visits), the patient requested lengthening the time betwe en visits as she felt she was function ing be tter and wanted to try it myself. A lthough th is was granted, she was advised that she could always return to the old schedu le if she fe lt it necessary, but that she did seem ready to use her own strong resources. Eventually she was seen every 46 months, with on ly an occasional phone call in between. She continued to see her primar y doctor at 6-month intervals; this physician was given su ggestions about h ow to work with a person with Mr s N's character traits and psychological defenses. He was encouraged to avoid the use of medications as she seemed to experien ce them as the physician's wish to be r id of her.

Case 2

The following case vignette illustrates the application of CBT pr inciples to SD. Ms J, a 48-year-old fe male, raised in Mexico, with a very difficu lt and impoverished childhood, emigrated to th e United States 6 years prior to treatment in search of a better life, plann ing on earning enough money to return to Mexico and live more comfortably. Married at a very ear ly age , and with three children, she had separated from her husband 1 year previously due to domestic violence that had started early in th e marriage and worsened after her grown children left the house. Ms J was referred by the social worker at her primary care center after she complained to her physician about mu ltiple somatic symptoms. At the time of the referral, she was living with her oldest son, his wife, an d children, serving as the children's caretaker. Symptoms included stomach aches, back pain, joint pain, arm pain, chest pain, headaches, menstrual irregu larities, urinary pain and problems, burnin g in her genitals, vomiting, nausea, diarrhea, excess gas, difficu lty digesting certain foods, difficulties with her sight and hearing, difficu lties with balance, fatigue, throat pain/problems, and sexual dysfunction, all of them medically unexplained. The psychologist's evaluation revealed that Ms J met fu ll criteria for SD. She also had significant depression and anxiety symptoms. Therapy consisted of a 10-week CBT program at the primary care clin ic as part of an ongoing study. At the first session, the patient discussed her physical symptoms and her thoughts about causes of her symptoms. She thought many of her pain symptoms were related to exposure to hot and cold temperatures. She did acknowledge that the

stress of leaving her husband and adjusting to life without h im may have precipitated many of her symptoms. She was able to connect stressors with symptoms. She welcomed the use of diaphragmatic breathing and was able to utilize the exercise as a way of lowerin g stress levels as we ll as creating time for herself. Because of her past h istory of abuse and deprivation s, encouraging pleasurable activities as we ll as utilizin g distraction techniques was important. As treatment progressed, Ms J was able to exercise on a daily basis, walking approximately 15 minutes a day. Furthermore, she listened to music as a for m of distraction from her physical symptoms, allowing the accompanyin g relaxation to lower her stress leve ls and decrease physical symptoms. Sleep hygiene was another focus of treatment. Ms J did n ot have a routine for sleeping. She complained of fatigue and awakenin g with bodily pain . Setting a routine of at least 78 hours of sle ep per night helped to structure her day, changing her perception of pain upon awakening and decreasing feelings of fatigue throughout the day. The final focus of treatmen t was to challenge dysfunctional thoughts. Ms J's pessimistic outlook of her life included conviction that: her symptoms wou ld never get better; she wou ld die young; and she was a burden on her children (even though she helped them raise their own ch ildren by carin g for them while the parents worked). By he lping her look at her thought processes and teachin g her the skills necessary to question an d change them, she was able to decrease her symptoms and improve her quality of life. This included assertiveness train ing to

address her inability to express her own needs and her low se lf-esteem. During the last session, Ms J and her psychotherapist discussed a plan to continue to examine dysfunctional thinking, to exercise, to adhere to a sle ep routine and engage in pleasurable activity to he lp maintain the acqu ired behavioral and cogn itive techn iques that h ad sign ificantly decreased her physical symptoms, including cessation of headaches and leg pains.

As with other somatofor m disorders, clin ician s who subscribe to the conceptualization of h ypochondriasis as a learned behavior will lean towards CBT approaches, while be lievers in the pr imacy of

developmental, interpersonal, or character structure as explanations of hypochondr iasis will favor psychoanalytic/psych odynamic approaches. Differentiating the disor der as pr imary or secondary will influence treatment (Speckens, 2001), especially with a preference for psychopharmacologic treatment for accompan yin g diagnoses of an xiety or affective disorders. In spite of a wide choice of therapies, controlled studies showing therapeutic super ior ity of one over another have been rare.

H ypochondr ia sis
Clinical descr iptions of h ypochondr iasis today are impressive ly consistent with those of earliest times and have been distilled and formalized in DSM-IV as follows: preoccupation with fe ars of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms, with duration of at least 6 months; the preoccupation persists despite appropr iate medical evaluation and reassurance; the be lie f is not of delusional intensity and is not restr icted to a cir cumscr ibed concern about appearance; the preoccupation cau ses clin ically sign ificant distress or impairment in social, occupational, or other important areas of function ing; the preoccupation is not better accounted for by generalized anxiety disorder, pan ic disorder, a major depressive episode, separation anxiety, or another somatoform disor der.

Rese arch
There has been a paucity of controlled studies of the treatment of hypochondr iasis, but past reports of several case series of cogn itivebehavioral psychotherapy h ad suggested benefits (Kellner, 1982; Salkovskis and War wick, 1986; War wick, 1989; Logsdail et al., 1991; Visser and Bouman, 1992). Kellner's study de monstrated improvement in 36 patients with behavioral interventions that corrected misinfor mation and distortions and de monstrated to patients how these factors contributed to misattr ibution and persistent fearful beliefs. More recently, several controlled studies have confir med the earlier suggestions of the effectiveness of cogn itive-behavior al interventions. A recent review (Kroenke and Swindle, 2000) from 1966 to 1999 identified 31 controlled studies, 29 of which were randomized in the treatment of a variety of somatizing syndr omes. In th is survey, CBT-treated patients improved sign ificantly mor e than control subjects in 71% of studies, with a trend of improveme nt in an additional 11% of studies. In one such controlled study, hypochondr iacal patients were randomly assigned to either individual CBT or a no-treatment waiting-list. After 4 months of weekly treatment, 76% of treated patients showed significant improve ment, sustained in 3-month follow-up (Warwick et al., 1996). This finding has been replicated in other randomized controlled trials (Speckens et al., 1995). O ne such study (C lark et al., 1998) compared treatment of 48 patients with cogn itive therapy to beh avioral stress management and a no-treatment wait-list control group. Both therapeutic groups were effective, maintain ing improvement after 1 year, with cogn itive treatment showing more improvement in hypochondr iacal measures than on general mood disturbance at 3 months follow-up. A recent controlled study (Barsky, 2004) randomizing patients to individual CBT or standard medical care appears to have shown sign ificant beneficial effects at one year follow-up with CBT. The

Conceptu al iz ation
While there is general agre ement that hypoch ondriasis is a mental disorder categor ically distinct from others, some subscribe to a dimensional concept in wh ich hypochondr iacal symptoms e xist on a continuum from heightened awareness of bodily function to extreme delusional bodily preoccupation. Some consider distinction s between health anxiety, disease phobia, and disease con viction (Barsky and Wyshak, 1989); panic (Furer et al., 1997); a variant of obsessivecompulsive disorder (OCD) (Hollender, 1993) or a personality disorder (Tyrer et al., 1990). Psych oanalytic concepts are retained in the view that hypochondr iasis is a defensive reaction against P.251 the guilt of aggressive impulses an d overwhelming fear of ann ihilation (Vaillant, 1977; Lipsitt, 2001a).

distinction in many studies between cogn itive and beh avioral treatment is not always clear. One study (Bouman and Visser, 1998) evaluated the effectiveness of pure time-limited cogn itive or behavioral interventions in 17 patients in 12 one-hour sessions. Patients in both treatment groups showed equivalent improve ment over controls on specific measures of hypochondr iasis and depression. However, nonspecific factors such as patient motivation, therapist attitudes, and the therapeutic re lationsh ip could not be ru led out as contributing factors (studies of these important nonspecific dime nsion s of treatment in somatizing disorders are conspicuously lacking in the research literature). Treatment preference by patients may also in fluence outcome (J. Walker et al., 1999). Group therapy using cognitive-edu cational methods has had reported success in several studies (Barsky et al. 1988; Stern and Fernandez, 1991; Avia et al., 1996). With an educational focus, studies showed significant reductions in illness fears and attitudes, fewer somatic symptoms and long-term benefits in dysphor ic mood and we llbe ing. A study of 96 patients receiving combined individual and group intensive inpatient CBT showed substantial improve ments or re covery fr om hypochondr iacal symptomatology (H iller et al., 2002). Predictors of poor outcome an d course of illness were h igher degree of pretreatment hypochondr iasis, more somatized symptoms and general psychopathology (as measu red on Symptom Checklist -90R), greater dysfunctional cognition, h igher leve ls of psychosocial disability, and more extensive utilization of healthcare resources. Tr eatment was admin istered on a daily basis individually and in grou ps according to a therapy manual (Rief and Hiller, 1998). Goals of treatment were defined according to cu stomar y CB T principles: identification and modification of dysfunctional perceptions and thoughts; impr oved inte rpersonal and occupational function; and decreased dependency on healthcare resources. Educational and explanatory interventions, physical exercise, assertiveness train ing, progressive relaxation, and biofeedback were included in the manualized treatment. Most studies involve patients already ut ilizing either mental or physical healthcare syste ms and not the commun ity at large. In order to tap this resource and to assess effe ctiveness of interventions on lower-leve l hypochondr iasis, one study in vited, by advertise ment, participants to apply for an educational course called Coping with Illness Anxiety (Bouman, 2002). S ix 2-h our sessions, each dedicated to specific themes about hypochondr iasis, were held for 21 participants in four grou ps of five to six, facilitated (not treated) by two graduate students of clin ical

psychology trained in individual cogn itive-behavioral techniques, using a detailed manual. Parameters for hypochondriasis and depression (on selected pre- and posttest measures) sh owed impr ove ment at 4 weeks and 6 months following the course, suggesting that this is an acceptable, effective, and probably low-cost way to reduce hypochondr iacal psychopathology, potentially applicable to nonhospital, nonclin ic general medical practice. Other uncontrolled studies have shown benefits of br ief explanatory therapy (Kellner, 1986; Barsky et al., 1988; A via et al., 1997; Lloyd et al., 1998; Papageorgiou and Wells, 1998). A more recent study of 20 patients randomly assigned to a treatment group and a wait -list group con firmed the benefits of explanator y therapy on helping patients maintain control of symptoms but with little change in symptomatology (Fava et al., 2000). E xposure, imaginal, and response-pre vention therapies are also said to help correct misin formation or misperception, but no controlled studies are reported (Logsdail et al., 1991; S isti, 1997). Very few psychoanalytic studies e xist. One Span ish study reports effectiveness of group psychoanalytic treatment (Garcia Campayo and Sanz Carrillo, 2000). The few reports on psychodynamic or psychoanalytic treatment of hypochondr iasis generally warn of the negative consequences of uncovering or interpretive therapies that have a high r isk of promoting quasi autistic withdrawal, tormenting self-observation, and othe r regressive behaviors (Nissen, 2000). Th is is not to say that psychoanalytic and psychodynamic precepts do not have applicability in establish ing and enhancing appropriate therapeutic relationships and treatment approaches in the management of hypochondr iacal patients (Lipsitt, 2001a,b). The role of reassurance in hypochondr iasis has been a controversial one. While DSM-IV has made inability to reassure hypoch ondriacal patients a criterion of diagnosis, virtu ally all therapy reports include reassurance as one of many interventions. The ease with wh ich somatizers can successfu lly be reassured varies with the chron icity an d intensity of symptoms, personality variables in the patient, attitu des, and treatment style of the therapist (Kath ol, 1997). Starcevic has pr ovided a thoughtful and comprehensive overview of the var ietie s, pitfalls, and uses of reassurance in the treatment of hypochondr iasis (Moene et al., 2000; Starcevic, 2001). Re assurance is regarded by cognitive-behavior therapists as a safety behavior for patients that interferes with progress and therefore should be avoided.

Key p ractic e pr inc i ples


Although there have been suggestive case series reports that pharmacotherapy may be h elpfu l in some cases of hypochondr iasis

(Fallon, 2001), there are in sufficient controls to sugge st that drug treatment has any sign ificant advantage over long-ter m supportive therapy. It wou ld appear that psych otherapeutic interventions work in the context of an interested, accepting, and concerned relationsh ip. Suggestions for enhancing this re lationsh ip are similar to those for managing SD. However, most hypochondriacal patients do n ot manifest the same intensity or demandingness seen in patients with SD. Some may e ven respond to judicious attempts at reassurance. If hypochondr iacal patients can be systematically maintained over an extended period of time, opportunity for insight development may arise, along with lessening of symptoms and improved functional adaptation. P.252

In other approaches, cogn itive-behavioral techniques show promise of hastening improve ment. The following case vignette illustrates a CBT approach to treating combined hypoch ondriasis and abridged somatization. Ms E is a 44-year-old marr ied for mer history teacher who stopped working to care for her son and ailing mother. Five years previou sly, she presented with symptoms of chest pain and heart palpitation s which, she feared, indicated cardiovascu lar disease. A cardiologist found no organic pathology and prescribed alprazolam, wh ich she took only once or twice before discontinuing it because it made her drowsy and spaced out. About 6 months later, Ms E again presented to her primary physician with new complaints, describin g severe headaches of several

10

Patients rarely appear with pure forms of hypochondriasis but may present with hypochondr iacal reactions to established physical disease. For example: A 58-year-old married woman with an obsessive-compu lsive personality style, following a mild myocardial in farction, became hypochondr iacally preoccupied with every minor physical sensation, certain that it was evidence of a fatal outcome. Accompanying depression was successfu lly treated with antidepressan ts, but fearful reaction to physical symptoms was chron ically unreassureable. The patien t was seen in supportive psychotherapy, with measured reassurance over time a major intervention, in half-hour sessions monthly for a year before she began to trust and accept her physicians optimistic repor ts. In each session, she anxiously reviewed medication directions to be sure she was meticu lously following medical or ders. B y the end of a year, she was able to be more flexible and less fearfu l, with little insight but increasing trust in the reassur ing comments of psych iatr ist and cardiologist, who coordinated their treatment.

months duration and worry that she had a brain tu mor. Her ph ysician had been trained in identifying somatization, and with Ms E could identify several rece nt stressors in her life. He referred her for a stress management program, be ing carefu l to schedule a followup appointment with h imse lf. Ms E hesitantly accepted and scheduled an appointment for the following week with a psychologist who worked in her pr imary physician's practice. A diagnostic evaluation included questionnaires to assess h er psychological health. The evaluation revealed that Ms E met criteria for abridged somatization and hypochondr iasis. She repor ted a history of irregular and painfu l menstruation, diarrhea, abdominal bloating, as well as the chest pain, palpitations, and headaches descr ibed earlier, that remained medically unexplained. For the next week, the patient was asked to complete a daily diary recording the type and se verity of ph ysical discomfort, recorded as very h igh (average daily diary score = 3.0 on a 15point Likert scale). She also endorsed

significant hypochondr iacal beliefs (Wh iteley Index = 11), and anxiety symptoms (Beck Anxiety Inventory score = 21). Ms E began a 10-session C BT. Although she expressed dou bts about th e potential benefits of th is treatment, she agreed to give it a try. Treatment began by teaching her to mon itor her physical symptoms and re lated thoughts and emotions. She quickly recognized that she often e xperienced headaches and chest pain after difficult interactions with her son and mother. She was instructed in the daily practice of progressive muscle re laxation and diaphragmatic breathing. O ver time, she began taking three relaxation breaks per day in order to e liminate muscular tension and to soothe herself. She also be gan to use relaxation techn iques when she fe lt angry at her son or mother. The next focus of treatment was teaching Ms E sleep h ygiene skills, including regulation of her sleep schedule and restriction of her time in bed to sleeping. She said that even though she felt exhausted at the e nd of the day, she experienced early insomn ia (at least 1 hour) every night. She used her r elaxation skills just prior to bedtime. After a fe w weeks, on most nights she began falling asleep with in 30 minutes. Ms E's daily activities were also addressed. Spending her days wor king so hard to take care of her son, mother, an d doing the housework, she was too tir ed to do anyth ing in the even ings e xcept rest on the cou ch. She and her therapist proble m-solved about reducing her respon sibilitie s and increasing her pleasurable activities. The advantages and disadvantages of enrolling her mother in a day treatment pr ogram were reviewed with Ms E, after wh ich she decided the potential benefits outwe ighed the costs. Once she had

freed up a part of each day, she began takin g increasingly long walks with a fr iend in the afternoons. A lso, she and her husband began scheduling a n ight out once every week. At the sixth session, Ms E and her therapist began discussing some of h er hypochondr iacal beliefs. She learned to look for evidence supporting and contradictin g her beliefs about having cardiovascu lar disease and a brain tumor. Substantial improvement in her chest pain and headaches was convincing enough for her to accept the possibility she may not have a progressive fatal disease. In addition, she cou ld remind herself th at her physicians had found no sign of or ganic pathology. Learning to create the symptoms on her own by running up a staircase to create palpitations and grindin g h er teeth to create headaches was further evidence that the existence of physical symptoms was not sufficient proof of the existence of a serious illness. In the final sessions, Ms E and her therapist delineated a relapse preve ntion plan. She agreed to continue using e ach of her newly acquired skills, i.e., re laxation e xercises, engaging in pleasurable activities/exercise, sleep h ygiene, and challenging distorted thinking. In addition, she continued to meet with her primary physician every 2 months for a check-up. She reported that these brief physical e xams helped remind her that she was physically health y. At the final session with the therapist, Ms E reported sign ificant improve ment in her headaches and chest pain. Her posttreatment qu estionnaires showed improvements in her daily diary scores (average = 1.3 on a 15 point Likert scale), hypochon driacal be liefs (Wh iteley Index = 5), and anxiety (B eck Anxiety Inventory score = 10).

11

A final report to Ms E's pr imary physician described her progress and encouraged h im to continue see ing her every 2 months for br ief physical e xams and to discuss her relapse prevention plan with her.

and response prevention, more recent therapeutic tr ials have stressed patients treated in small gr oups with CBT for 12 weekly 90-minute sessions, showed significan t improvement in both body dysmorph ic disorder (BDD) and depressive symptoms (Wilhelm et al., 1999). A 2year follow-up of behaviorally treated patients P.253 followed with 6-month maintenance programs prevented symptom relapse and assisted in patient se lf-management of lapses typically associated with BDD (McKay, 1999). A randomized tr ial of CBT combined with exposure and response prevention in 35 women for eight 2 -hour sessions foun d sign ificant improve ment in se lf-image, self-esteem, and psych ological distress compared with the untreated wait-list control group (Rosen et al., 1995). Another study (Veale et al., 1996) of 19 patien ts randomly assigned to CBT or wait-list control gr oup for 12 weeks showed significant improve ment (77%) on specific measures of BDD and depressed mood. BDD patie nts were found to be different from th ose with real disfigurement who sought cosmetic surgery or were emotionally we ll-adjusted, as we ll as fr om healthy con trols without defect.

12

the promise of CBT (Cororve and Gleaves, 2001 ). An open case ser ies of

Body d ysmo rphic disor der Backgro und


This particular somatizing condition has on ly recently (Amer ican Psych iatr ic Association, 1987) been included under th e rubric of somatofor m disorders and is usually considered a subtype of hypochondr iasis because of the presence of intense fe ar of and be lief in bodily defect, u sually expe rienced subjectively as ugliness. It is de fined as a distressing preoccupation with imagined de fects of appearance or excessive concern over min or physical anomalies, unaccounted for by other mental disorders. Complaints may focus on the head and face, but may in volve an y part of the body. With onset in adolescence, man y adults seek corrective sur gery from plastic surgeons and dermatologists (Ph illips, 1996).

Conceptu al iz ation
Poorly understood, it had previously been considered a delusional aspect of other psych iatr ic disorde rs. Psychodynamic authors have ascr ibed it to a defense again st more overwhelming an xiety, with displace ment from other emotional concerns to dissatisfaction with appe arance or body configuration (Fisher, 1986). Others con sider early experience and learning of greatest importance in affecting self-image, self-esteem, and bodily self-approval (Ph illips, 1996). More contemporary thought regards dysmorphoph obia as part of a ph ysiological spectrum disorder that includes eating disorders, affective disorders, and OCD (Hollander et al., 1992), with its man ifestation a function of cu lture and environment (Pope et al., 1997). Perhaps the disorder can best be conceptualized as a body image disorder with social, psychological, and possibly biological influences (Cororve and Gleaves, 2001).

Studies have n oted that BD D shares many features in common with OCD, including responsiveness to CBT, medication, and psychosocial rehabilitation. Ninety-six patients with OCD were compared with 11 BDD patients in a 6-week intensive partial hospitalization program assessed with rating scales for depr ession, anxiety, and global symptomatology (Saxena et al., 2002). The two groups showed similar direction of responses to SSRIs and antipsychotics in depressive, anxiety, and obsessive-compu lsive symptoms, although BDD sh owe d greater improve ment in depression and anxiety. It was con clu ded that BDD can respond to intensive, mu ltimodal treatment. CBT, with or without medication, appears to be favored as the treatment of choice for BDD.

Key p ractic e pr inc i ples


The importance of establishing a good therapeutic alliance has special salience with BDD patients as they are often reluctant to accept psych iatr ic or psychological care, be ing strongly attached to the idea that their defects require surgical or medical correction. H istor ytaking shou ld follow the usual recommendation s for somatizing patients, with special attention to qu estions about self-image, self-esteem, previou s forms of he lp-seeking, exper ience with surgical or der matologic treatment, age of onset, avoidance of occupational or social situations

Rese arch
Until recently, treatment recommendation s were fairly pessimistic, with major intervention consisting of warn ings to cosmetic surgeons to screen carefully patients requesting surgery for body changes, keeping in mind the fair ly h igh incidence of disappointment with outcomes (Phillips et al., 2001). Wh ile early case reports in dicated successfu l outcomes with exposure, systematic desensitization, self-con frontation,

or personal/sexual relation ships (because of se lf-con sciousness), and leve ls of perceived distress. Special attention must be paid to comorbidities of anxiety an d/or depression, as it has been reported that as man y as 29% of BDD patients attempt su icide (especially women concerned about perce ived facial defects). In the context of a therapeutic relationsh ip, S SRIs appear to be the first line of treatment, but require doses in excess of those for treatment of depression (e.g., flu oxetine 4080 mg/day and fluvoxamine 200300 mg/day). Concurrent CBT is recommended, inclu ding exposure and desensitization techniques, imagery, and se lf-confr ontation. Long-term maintenance on therapeutic leve l doses of medication is advised because of high incidence of relapse. Meetin gs with family me mbers, spouse, or significant others can help inform, educate, and provide understanding supportive assistance for the patient.

psychoanalytic theory, on the other hand, describes symptoms as partial expression of the conflict without conscious awareness of its significance (Barsky, 1995). Some have suggested a str ong relation ship between childhood

13

compromise for mations with primary gain of conflict resolution through

traumatization by sexual or physical abuse and a later propensity for conversion disorder (Roe lofs et al., 2002). However, one study of 30 patients with motor conver sion disorder, with high de grees of parental rejection and low levels of affection and war mth as pe rceived by the patients, did not con firm an association of ch ildhood physical and/or sexual abuse with con version disorder (B inzer and E isemann, 1998).

Rese arch
Although a var iety of explanations and treatments have been reported in the literature, there is little systematic research available. Using hypnotherapy, one of the oldest reported treatments, a comprehensive treatment program of 85 patients suffering motor con version symptoms reported unusual and unexpected responses in 16 patients during hypnosis (Moene and Hoogduin, 1999). Wh ile raising caution about th is intervention, the authors also suggest that such events may offer opportunities to he lp patients enhance understanding and gain better control over symptoms. On e of few randomized controlled tr ials (Moene et al., 2002), treating 45 inpatients comprehensive ly with symptomoriented as we ll as expression- and insight-or iented techniques, found significant improve ment in all subjects, whether hypn osis was used or not. Furthermore, hypnotizability was not predictive of treatment outcome. A retrospective case series of eight ch ildren ages 918 with conversion disorder involving motor disturbance of gait, treated with inpatient behavioral manage ment using a reward system, reported that all patients attained nor mal gait and improved activities of daily living (Gooch et al., 1997). T o maintain improve ment after discharge, instruction of the patient and family in pain and stress manage ment appeared essential. Lackin g controlled tr ials, other case reports include effectiveness of negative r einforce ment (Campo and Negrin i, 2000), culturally-re levant (shamanistic) treatment (Razali, 1999) showing the benefits of indigenous psychotherapy, and rehabilitative inpatient treatment (Watanabe et al., 1998) u sin g functional and behavioral therapies and extensive psychosocial support to produce rapid improve ment in hyster ical hemiparesis (mean length of stay 11 days). One study of psych ological defense conste llations comparing 19 patients diagn osed with conversion disorder to 32 healthy non patients showed nonpatients better able to perceive and express affective response to a

Conver sio n d isor d er Backgro und


Clinical interest in hysteria very likely set the stage for subsequent psychoanalytic thought, for of all the somatizing disorders, it was clear ly the one most associated with psychological con flict. Some say it is the most common of all the somatoform disorders (Schwartz et al., 2001). Patients usually present with complaints of weakness, gait disturbance, blindness, aphon ia, deafness, convu lsion s (pseudose izures), or tremors. Of patients entering a clin ical setting with complaints of motor disability and diagnosed con version disorder, 33% may be expe cted to have other Axis I diagnoses, and 50% Axis II diagnoses (B inzer e t al., 1997). Characteristics of la be lle indifference (bland emotional reaction to presence of otherwise alarming symptoms), hysterical or h istr ion ic personality and secondary gain, often associated in older literature with conversion disorder, appear to have no predictive diagnostic significance. Ph ysical illness and conversion disorder are not mutually exclusive.

Conceptu al iz ation
In addition to the psych oanalytic mode l of conversion alluded to above, others have suggested physiological and behavioral models. The neurophysiological conceptualization proposes an inhe rent defect in poor ly identified brain functions, especially of the dominant hemisphere (Drake, 1993), interfering with verbal association s, while the behavioral theory suggests fau lty ch ildhood learn ing, with the ch ild exercising learned helplessness utilize d for secondary gain and control of interpersonal relationsh ips (Barr and Abernathy, 1977). The

stimu lus picture, supportin g the psychoanalytic hypothesis that conversion symptoms are nonverbal communications r eplacing perception and verbal expression of emotion (Sundbom et al., 1999). A recent report high lights th e benefits of a mu ltidimensional treatment approach that utilizes inpatient, partial hospitalization , and outpatient treatment employing psych odynamic, behavioral, psychosocial, h ypnotic, pharmacologic, and cu lture- and re ligion-focu sed tech niques (Schwartz et al., 2001). To test the clin ical theory that conversion disorder is promoted or perpetuated through questioning by parents and physicians, one study compared the interrogative suggestibility of 12 patien ts diagnosed with conversion disorder with a matched grou p with con firmed neurological disease, concluding that in terrogative su ggestibility was of no significant importance in th e etiology of conversion disorder (Foong et al., 1997). Clin icians often caution that conversion disorder sometimes reveals subsequent organ ic disease in long-term follow-up. To assess this potential, 73 patients with P.254 medically unexplained motor symptoms were assesse d and followed for 6 years, with on ly three patients man ifesting new organ ic neurological disorders, in contrast to th e 1965 classic study of S later and Glithero (1965) showing 50% new neurological or psychiatr ic disorders in 10 years (Crimlisk et al., 1998). Others have also confir med a decrease in percentage of patients in itially diagnosed with con version disorder who later are identified as having an organ ic (neurological) disorder (Mace and Trimble, 1996; Moene et al., 2000). Long-term chronic patients were at risk to deve lop SD in the absence of diagnosis of another disease.

development of entrenched SD. Once chron icity has developed, intensive treatment may make u se of all treatment modalities, including hospitalization, individual or group therapy, insight-oriented therapies, behavioral techniques, negative re inforce ment, hypnosis, sodium amytal interview, physical therapy, biofeedback, relaxation tr ain ing, and medication (pr imar ily for comorbid anxiety, depression or other somatofor m disorders). The therapeutic value of a tr usting ongoing relationship is illustrated in the following case: A 54-year-old married man was be ing treated pharmacologically and mon itored month ly with supportive half-h our visits for chron ic recurring depression. One day he paid a rare visit to his hated mother residin g in a nursing home followin g a seriou s stroke. He found himself ph ysically distresse d in her presence, with nausea and a concern he might vomit and hastily had to leave. One day later he developed a left-sided he miparesis. He had virtually no capacity for insight or appreciation of the possible connection between his mother's ailment and his acute physical reaction. His therapist, a consu ltation-liaison psych iatrist based in a general hospital, obtained the min imum essential tests an d consults to ru le out bona fide neurological disease. T he therapist interpreted the complete ly normal studies to the patient, not that noth ing was the matter, but rather that the tests are reassuring that th is is a completely reversible illness. Because of the the rapist's acquaintance with hospital medical and nursing staff, arrangements cou ld be made by a team effort for a brief medical hospitalization for th is patient, during wh ich time he was treated very much as a true stroke patient wou ld be, with rehabilitation, physical therapy, respiratory therapy, and the like. With in appr oximately 3 weeks, with virtually no psychotherapeutic intervention except regular supportive visits by h is

14

Key p ractic e pr inc i ples


Without adequate controlle d studies providing evidence-based direction, treatment choice will depend large ly on therapist preference and experience. The usual caveats on h istor y-taking prevail, with special attention to h istory of trau ma, se xual and ph ysical abuse, and family histor y of conversion symptoms. Physical examination must pay particu lar attention to ru lin g out neurological diseases, such as multiple sclerosis and other peripheral and central nervous system disor ders. Routine laboratory studies are indicated as well as EE G (to distingu ish between epilepsy and pseu doseizures) and other special studies (e.g., MRI, X-rays, spinal tap, etc.) to ru le out possible organic etiology. Many conversion syndromes will remit spontaneously with understanding and support, but early intervention can forestall potential chronicity and

therapist, h is illness had completely and miracu lously remitted, with neither physical residual nor understanding by him of how h is feelings about h is mother may have influenced h is physical response. H is depression continued. Offering psychological interpretations/explanations or reassurance too early may subvert treatment efforts; on the other hand, reassuring patients that critical tests are normal and that symptoms will eventually improve may hasten improvement. Because repression is very strong in some conversions, patients will be initially reluctant to divu lge or explore early contr ibuting conflicts or experience. Th is may have to wait on a comforting/comfortable, trusting an d safe relationship before there can be progress, especially true for ch ildren and adole scents where the support and participation of family, teachers, and physician s may be required in a team effort; often the pediatrician, with psych iatric or psychological backup consu ltation, may be the best option to assume the role of therapist. An y implication of malinger ing will be very counterproductive. Accompanying comorbid depression, anxiety, and behavior proble ms may respond to accepted pharmacologic ministration s. Use of h ypnotic or narcoleptic techniques, if utilized, must be tentative ly offered to patients whose fear of passivity or loss of control may indu ce over whelming anxiety. Behavioral interventions should focus on improvin g self-esteem, capacity for emotional expression and assertiveness, and ability to commun icate comfortably with others.

medical narratives, capable of defying easy diagnosis. They may be male or female, although earliest reports are almost entirely of men; it is now reported that most patients with factitious disorder are women between ages 20 and 40. They have histories of multiple hospitalization s, frequently in var ious locations (peregrinating), and may display multiple surgical scars (establish ing the veracity of their stor ies). Presentations may be of actual se lf-induced symptoms, of factitiou s medical h istor y, e mbellishment of naturally-occurring anatomical anomalies, or the offering of (usually forged) docume ntation of previous treatment. They are generally very receptive (un like malin gerers) to invasive procedures, often at high risk of morbidity or mortality. Being confronted with the possibility of their deception often evokes denial, hostility, and/or flight. Rar ely will patients with physical factitia accept referral for psych iatric treatment.

15

Conceptu al iz ation
Understanding why an yone wou ld intentionally wish to be sick has challenged the best clinical and theoretical minds. Psychoanalytic hypotheses posit the need (both conscious and unconscious) to master the anxiety that accompan ies fear of real illness with repetitive reenactment of the ch ild's doctor game, playing both active and passive sexualized roles as victim (masoch istic) and victimizer (sadistic). Others hold that it is a man ifestation of borderline personality disorder in wh ich identity proble ms and conflicts over control and author ity are acted out in the theatre of medicine, with rage projected on to the inept, humiliated, snookered physician. Still other suggestions include a stress response to having been thwarted in the ambition to become a physician, to a reaction to serious loss, or a histor y of illness, abuse, or hospitalization of oneself or other meaningful figures. Presumed histories of neglect, abandonment, or abuse support the notion that factitious patients seek nurturance and dependence, albe it in faulty ways. The idea that patie nts are merely seeking attention seems un convincing as there are so many other ways to behaviorally satisfy th is wish (Lipsitt, 1982). Factitious illness by proxy invokes similar explanations in a mother (rarely a father) who vicariously fu lfills psychological needs through illness perpetrated on a child.

Factitio us diso rde r Backgro und


Originally known on ly by its most extre me clin ical pre sentation in Munchausen's syndrome, the category of factitious disorders has on ly recently (and perhaps argu ably) been included in the domain of somatoform disorders (DSM-IV). Clinical presentation s meet diagnostic cr iteria for factitious disor der if they: (1) intentionally fe ign physical or psychological signs an d symptoms; (2) appear motivated on ly to assume the sick role; and (3) reveal no in centives characteristic of malingering. Psychological and physical signs an d symptoms may present separately or in combination. Patients are often very inte lligent, with a good grasp of medical knowledge an d language, and frequently occupied in some aspect of medicine or re lated fie lds. They are persuasive and creative in their

Rese arch
The paucity of reliable findings in factitious illness arises from the elusiveness of these patien ts as we ll as their fabr icated histor ies. Furthermore, their inability to form genuine re lationsh ips with staff and physicians who are often biased and resent patients deception reduces

opportunities for mean ingful cooperative study. In th is context, it is not surprising that no controlled studies exist and it would appear un like ly that they will be possible in the future. Reports of therapeutic trials consist almost entire ly of individual case reports (Fras and Cough lin, 1971; Earle and Folks, 1986; Merrin et al., 1986), some of which report variable success with treatment. In one P.255 reported series of 24 patie nts, 10 agreed to engage in psychodynamic psychotherapy for up to 4 years, with favorable progress, according to the author (Plassman, 1994). Another treatment effor t was reported to have modified re liance on the sick role in two patients in an inpatient behaviorally or iented progr am designed to avoid con frontation (Solyom and Solyom, 1990).

patients than psych otherapy alone, in hopes that the patient may ultimate ly accept and deve lop a trusting relationsh ip with a pr imary

16

physician. Phar macotherapy can be offered for accompanyin g comorbid Axis I disorders. When factitious illness by pr oxy involves ch ild abuse, it is essential to notify prope r child care agencies. Offer ing protective care and perhaps therapy to the afflicted ch ild and family therapy to the parents and ch ild may be u seful. It shou ld be kept in mind that, although rare, factitious patients may occasionally lau nch malpractice suits (Lipsitt, 1986). Other isolated and occasional idiosyncratic interventions have been extensive ly revie wed e lsewhe re (Eisendrath, 2001). There are no controlled treatment studies.

Summa ry of gen er al guid el ines for tr eatment of somatofo rm d iso r ders


Histor ically, the treatment of somatizing patients has been considered difficu lt and frustrating (Lipsitt, 1970, 1992). These patients tend to be dissatisfied with the ir medical care and may complain when their symptoms do not qu ickly re solve. Patients with multiple unexplained physical symptoms report h igh rates of disability. These patients also have a propensity for remain ing idle, avoiding productive an d meaningful activities (Katon et al., 1991). They tend to overutilize primary care and specialty services; it has been estimated that their expenditures are two to n ine times the average of nonsomatizin g patients (Smith et al., 1986; Barsky et al., 2001). In our review of psychothe rapy of somatofor m disorde rs, it appears that available studies, both controlled and uncontrolled, fail to establish defin itive ly any individual psychotherapy as clearly superior to any other. In th is, there is confirmation of earlier reports of psychotherapy research (Bergin, 1971; S mith and Glass, 1977; Hartley, 1985; Lin et al., 1991). Wh ile case reports suggest that cogn itive-behavioral approaches may be preferred in this era of urgent de mand, reduced funding, and stringent regu lations, adequate studies h ave yet to be performed that establish long-term benefits with th is approach as superior to that of others. We are led to the conclusion that it is very like ly that the ultimate efficacy of any therapeutic intervention with difficu lt somatizing patients is realized as much (or more) through the nature of the patienttherapist relationsh ip as through any other specific intervention. If this is indeed the case, then we mu st emphasize aspects of the therapeutic relationship that wou ld appear to enhance an optimal outcome with this large group of patients. We therefore conclude with a su mmar y of the challenges presented by patients who suffer from somatoform disorders and su ggestions to deal with those

Key p ractic e pr inc i ples


For reasons stated above, difficu lty in forming an alliance with factitious patients is a major impediment to treatment. Ear ly distinction between malin gering an d factitia may be possible if the seeking of secondar y gain in the for mer is detectable. Willingness to undergo risky or painfu l procedures is more apparent in factitious disorder. Occasionally, it is possible, especially with th e less severe cases, to establish a relationship that facilitates gathering a more or less accurate history and makin g a psychiatr ic r eferral for continu ing management. If there is a hint of a therapeutic alliance, one may try to interest the patient in explanations of illness as r elated to stress or to he lp find alternative ways other than the sick role to obtain gratification. E arly detection is encouraged by verifying elements of history either by notin g incon sistencies in early background or by checking with other sources regarding previous hospitalizations and treatments. T his latter endeavor, when exercised without the patient's conse nt, raises ethical questions without decisive answers. Laboratory studie s can he lp to ru le out impostured diseases. Customary medical treatme nt is necessary for any self-indu ced pathological conditions. Working with h ospital staff to control impulses of angry retribution may h elp to gain patients trust and confidence, in anticipation of further contact. D irect or especially insensitive confrontation of deception in these patients usually results in heated denial, outbursts of rage, or elope ment, with potential further regressive and se lf-destructive behavior. If atte mpted treatment intervention is su ccessful, it will like ly be for the long term. Collaborative care between psych iatrist or psychologist and pr imar y care physician may have more long-term success in containing factitious

challenges. Such an allian ce will depend upon the respective contribution s of patient an d therapist to the re lationship they establish between themselves.

timin g and degree of reassurance must be based on adequacy of data and the trust and secur ity of the relationship. Somatizing patients will be most comfortable revealing histor ical details in physical or somatic terms, but th is shou ld n ot deter an

17

Cha llen ges Buil din g a tru stin g al li ance


Chronically somatizing patients approach each ne w medical encounter with both magical expectations and great pessimism and distrust, based on previous experiences with doctors who convey disinterest or disbelief in the patient's complaints and suffer ing. Building a tr usting alliance in this context must begin with respect for the patient's symptoms and acknowledgment of the ir validity; a tolerance for repetition; an attitude of active, receptive listen ing; and a neutral approach that is neither dismissive, confrontational, nor overly reassur ing. It is on ly with time, consistency, and continuin g trustworth iness that a relationsh ip will ripen into a trustin g potentially therapeutic partnership. Promoting a certain leve l of dependence will fu lfill a requ irement for a working allian ce, while re minders to the patient of areas of strength, survivorsh ip, and courage will support optimal self-regard and autonomy while avoiding regressive tendencies. The manner in wh ich the clin ician takes a h istory as part of a psychotherapeutic evaluation may pave the way for a therapeutic alliance. Somatizing patients come to a new encounter not on ly with a string of disappointments and thin ly ve iled anger, but also with a r ich histor y of many previous e ncounters, mu ltiple tests, and procedures (often redundant and without clear rationale). They ar e designated the thick chart cases of medical practice. The prospect of revie wing their medical records is a daunting challenge, often establishing a negative mind-set in the busy physician on first acquaintance. When patients response to opening questions is It's all in the record, it is helpfu l to remind them that it is preferable to hear directly from the patient, to get a better sense of wh o that person really is, rather than read some impersonal remarks by others. Notations or forewarn ings of crocky patient (or other pejorative labe lings) shou ld be ign ored in favor of the physician's own assessment of the patient's illness behavior and pattern of interactin g. A good medical history shou ld not be short-cut on the basis of preformed expectations. Attempts to hastily r ush to psychological h istory-taking or explanations will fall on deaf ears, as this is rarely the somatizing patient's language or con ceptualization of illness. Like wise, prematur e reassurance, wh ile seeming appropr iate to the physician, may be perceived by the patient hunge ring for connectedness as the ph ysician's disinterest or dismissiveness. The

exploration of sign ificant e vents (e.g., losses, trauma, disappointments, deprivation, and so on) surrounding earliest on set of symptoms. However, patients who do not acknowledge, recogn ize , or describe emotional react ions (alexithymia) may respond more readily to questions about physical symptoms than about depr ession or gr ief as responses to stressfu l events. Some histor ical details may n ot be revealed until the patient feels assured that a trustworthy relationsh ip exists; the more chron ic an d disappointing the patient's prior medical experience has been, the longer it will be before the patient reveals important h istor ical infor mation. As the history evolves, attitudes, beliefs, and attributions may become clearer, as we ll as certain patterns of interaction and illness behavior, that is, P.256 the ways that the patient fulfills the sick role. Distorted beliefs, contradictory ideas, and fe ars can be addressed at moments dur ing the gathering of h istor ical data when the patient appears receptive.

M ana gement
Because of the refractor ine ss of somatized symptoms to general interventions, physicians and therapists will be more successfu l with somatizing patients by adopting a car ing rather than a curing approach to these patients. Therapeutic zeal often is met with increased resistance to change. Rescue fantasies with these patients are usually thwarted, heightenin g the wou ld-be rescuer's frustration. Such frustration often fosters in tensified efforts at (usually inappropr iate) treatment, on the one hand, or specialty referral or dismissal on the other. Restraint in the use of medication is advised, although when positive ly in dicated for comorbid affective and an xiety states, it is best admin istered with an expression of modest expectations. Clear assign ment of appoin tment times at fair ly regu lar (but infrequent: approximately monthly) intervals is more effective than random appointments based on fluctuations in symptoms. Gentle limit -settin g can be accomplished by spellin g out a treatment plan from the beginn ing and then reminding the patient of the policy when testing-out of the therapist's commitment occurs. In time, with increasin g trust and comfort, the patient's repertoire will expand beyond the confines of symptom complaints. In quiring about the disappear in g symptoms is

unnecessary and may only suggest to the patient a gr eater interest in the patient's complaints th an in h is or her social wor ld and family relationships. When a solid working relationship is in evidence, therapists may fu lfill their pedagogical function by explain ing the causal connection between external stressors, ph ysiological repercussion s, and the experience of somatic symptoms. A lthough insight may be slow to develop, sufficient awareness of an emotional component may su ffice to e nhance receptivity to referral for specialized behavioral intervention. D iscussion of the variety of treatment programs and enlisting the patient's preferences will help to ensure acceptance of referral and follow-through in treatment. If referral is su ccessfu l, contact with the primar y care physician should be maintained with the patient to avoid a sensitive reaction to intimations of r ejection. Whichever for m of treatme nt the patient se lects, it is likely that a good outcome will be greatly en hanced by a strong relation ship of the patient with a pr imary care physician. Collaboration between the mental health professional and pr imary physician will strengthen the patient's be lief and trust in the interest of his or her treaters. In this context, patients are like ly to respond positively whether treatment is behaviorally, psychodynamically, or psychosocially or iented.

Barr, R. and Abernathy, V. (1977). Con version reaction. Differential Mental Disease, 164, 28792.

18

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Acknow ledg ments


Drs Lesley A llen and Ange lica Diaz-Martinez provided CBT clin ical vignettes. Carole Berney, M.A., assisted with references. This work was supported in part by NIMH grant RO1 NH60265 (Dr Escobar).

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