Since medicine's earliest beginnings, physicians have been perplexed and vexed by patients whose symptoms seem medically unexplainable and who respond poorly to treatment. In 1927, the legendary Francis W. Peabody, Harvard Professor of Medicine at Boston City Hospital, wrote that teachers and students are at risk of ‘… serious 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 the broad heading of ‘psychoneuroses,’ with the ‘ultimate causes… to be found, not in any gross structural changes in the organs involved, but rather in nervous influences emanating from the emotional and intellectual life which, directly or indirectly, affect in one way or another organs that are under either voluntary or involuntary 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 caring patient–doctor relationship. He is most famously quoted for his concluding statement that ‘… 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 ‘difficult patients’ since these perceptive words were written? Because organized medicine has had little success with these patients and perhaps because of the prickly relationships they have with their physicians, understanding of their illness behavior, diagnosis, and treatment have, over the years, moved from medicine into psychiatry's domain under the current rubric of ‘somatoform disorders,’ 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 cumulative experience and clinical wisdom but disappointingly few reliable well-controlled studies. With few research studies and attempts at classification that have been beset with confusion, controversy, and inconsistency, we are left confronted with uncertain treatments for uncertain disorders. But there are new advances appearing on the horizon.
This chapter reviews what is known about the psychotherapeutic interventions that have succeeded or failed with these disorders and the challenges they present to healthcare professionals. Matters of diagnosis, clinical description, prevalence, and etiology are covered sufficiently in other texts and will be touched on only briefly here. Similarly, detailed elements of psychopharmacotherapy remain beyond the scope of this chapter. Our focus will be on key practice principles of psychosocial treatments of the entire group of somatoform disorders. Each disorder will be discussed in terms of unique therapeutic requirements or specific pertinent research, concluding with a general therapeutic formulation appropriate to the entire group.
Detailed inspection of functional somatic syndromes reveals that all include common elements.
No gold standard to confirm or rule out the diagnosis.
Presence of multiple unexplained symptoms originating in several organ systems.
High levels of psychiatric comorbidity.
No clear pathophysiology; while a number of pathophysiological mechanisms have been invoked to explain many of these syndromes (e.g., symptom amplification, muscle contraction, catecholamine release, persistent neurobiological dysfunction, neurological hyperreactivity, elevated cortisol) no clear pathophysiological knowledge has emerged for any of them.
No consistent explanation emanating from physical and laboratory assessments.
No good fit with rules of allopathic medicine.
Comparable responses with certain psychological [e.g., cognitive-behavior therapy (CBT)] and pharmacological (e.g., antidepressants) interventions.
The presence of emotionally charged, highly politicized groups of patients/advocates. Indeed, patients with functional somatic syndromes such as ‘chronic fatigue,’ ‘fibromyalgia’, and in general, many of those who prefer other ‘medicalized’ labels such as Lyme disease, or ‘environmental disorders,’ have been forming highly passionate groups.
In 1991 excellent reviews of this topic appeared almost simultaneously on both sides of the Atlantic (Barsky and Borus, 1999; Wessely et al., 1999). These reviews underlined the many common epidemiological, clinical, and psychopathological aspects of these ‘functional’ syndromes in efforts to set the stage for much-needed collaborative research in this area.
Barring more convincing research evidence, it is ultimately one's personal definition of somatization that influences the selection of treatment: thus, therapists favoring the concept of a learned dysfunction may prefer cognitive-behavioral approaches while those theorizing a developmental failure in mothering, for example, may prefer more dynamic and supportive techniques, and so on.
While descriptive accounts of somatization abound, theoretical or causal explanations are scarce. In this context, and despite its dualism, we find the developmental schema of Max Schur (a psychoanalyst and Freud's personal physician) appealing as a well-rounded theory supported by experience. Schur (1955) posited that the infant is born with a capacity for only undifferentiated physical expression and it is not until the development of motor control, neural structures, and language (‘ego development’) that the child has the capacity for direct emotional expression.
According to Schur, the child passes from a totally somatized state to one that is gradually de-somatized. In the face of trauma, deprivation, developmental failure, and other debilitating factors, the child may revert (‘regress’) to re-somatizing states. Henceforth, somatization may be resorted to for the expression of ‘unspeakable’ emotional distress. Such a theory has some endorsement from studies that have shown a high correlation between medically unexplained symptoms and early childhood sexual and/or physical 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 and alexithymia (Sifneos, 1973). Further theoretical elaboration by Scheidt and Waller (1999) emphasizes the importance of the quality of early maternal attachment in determining later (adult) predisposition to somatization.
Another body of research, particularly within the last 5 years, has examined the efficacy of CBT for somatization. According to the research, CBT seems to help patients modify thoughts and behaviors that are associated with somatization and recognize the role of ‘stress’ in physical dysfunctions, such as sleep disturbance, fatigue, pain, and so on. Patients are subsequently helped to combat this effect via numerous behavioral techniques, including relaxation training and graded increases in activities. From a cognitive perspective, CBT helps these patients identify thoughts that contribute to increased stress, inactivity, and health concern. Often, these patients think catastrophically about their physical symptoms, leading to conclusions 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. Allen and associates (Allen et al., 2001) showed that CBT helped patients with full DSM (Diagnostic and statistical manual of mental disorders) somatization disorder (SD) significantly reduce their physical discomfort, anxiety, and depression, as well as increase their physical functioning. Other investigators have conducted 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 only in physical and emotional symptoms, but also in physical impairments and medical utilization.
Although CBT has been typically administered in mental health specialty settings, there seem to be a number of advantages to providing CBT in primary care, when working with somatizing patients. First, because these patients preferentially use medical services, providing CBT in primary care helps to match treatment to the somatizing patients’ expectations; somatizing patients are apt to feel more comfortable in the primary care environment. Second, patients suffering from medically unexplained symptoms often receive signals from others that their symptoms are less than genuine. For this reason, referral to mental health settings often conveys more stigma, and the perception that referral to a mental health facility invalidates their physical distress by suggesting that it is ‘all in their heads.’ As a result, patients often do not follow through with mental 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 between the mental health provider and the primary care physician.
As almost all individuals experience one or another physical symptom in a period of a week or two (Kellner and Sheffield, 1973; Pennebaker et al., 1977) it should be obvious that it is only when such symptoms exceed a threshold prompting medical help-seeking that the label ‘somatization’ is typically warranted.
It is the primary care physician, not the psychiatrist, who most often sees patients with somatizing conditions. Moreover, the multiple definitions for these syndromes that exist in psychiatry and medicine, make prevalence data very difficult to gather, and the frequent changes in the nomenclatures add to the confusion. Because most somatoform disorders are seen in outpatient practices, little is known about the prevalence of somatoform disorders in the general or psychiatric hospital. And because patients with somatizing conditions do not usually identify themselves as having psychiatric illness and will commonly reject referral to a psychiatrist if it is offered, the prevalence in psychiatric practice is probably less than in primary care.
In medical practice, somatization is tied to the issue of the ‘frequent consulters.’ These patients present with symptoms that change over time. They receive more medical diagnoses, have unhealthy 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 their high levels of psychological symptoms these patients are very unlikely to see themselves as ‘psychiatric’ patients, even though about one-fourth of them meet diagnostic criteria for major depression, 22% for anxiety disorders, 17% for dysthymia, and up to 20% for full DSM criteria for SD (Gill and Sharpe, 1999).
Although little is understood about the precise way in which the somatization process is mediated, some have suggested a central nervous system elaboration of stimuli, with ‘amplified’ perception (Barsky, 1992). Others have posited some kind of physiological reactivity or hypersensitivity (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 irrelevant stimuli in the same way, suggesting that some filter mechanism may be missing, making it difficult or impossible for the somatizer to ignore irrelevant stimuli. Psychological studies have demonstrated this ‘blocking’ action to occur more often in individuals who have either high or low hypnotizability as well as high scores on the Marlowe-Crowne Social Desirability Scale (Wickramasekera, 1998). PET scan studies (Garcia Campayo et al., 2001) have shown changes in somatizing patients that resemble those found in depressed patients. Other studies suggest that biological and pathophysiological changes may contribute to somatizing conditions (Fink et al., 2002).
In spite of their shared characteristics, each somatoform disorder shows variations in history, conceptualization, 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).
SD has been defined as a complex, usually chronic condition primarily of females with a history of multiple unintentionally produced physical complaints beginning 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 diagnostic threshold (quite arbitrarily, some have said), changed in DSM-IIIR to 13 total, and finally, in DSM-IV, modified to eight physical complaints referable to four pain sites or functions (e.g., back, chest, urination), two nonpain gastrointestinal symptoms (e.g., nausea, bloating), one nonpain sexual or reproductive system symptom (e.g., menstrual irregularity, loss of libido), and one pseudoneurological symptom (e.g., urinary retention, aphonia, 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 period of several years accompanied by significant impairment of social and occupational function and high utilization of medical resources, usually resulting in either ineffective and/or unnecessary medical/surgical treatments. Many encounters of these patients with physicians generally evoke frustration in both parties of the relationship.
Several researchers, responding to an expressed need for a diagnosis of subtypes seen in primary care in the range between full-fledged SD and the undifferentiated form, have offered suggestions of ‘somatization syndrome,’ ‘abridged SD’ (Escobar et al., 1989), ‘polymorphous,’ ‘multisomatoform’ (Kroenke et al., 1997), or ‘polysomatoform’ (Rief and Hiller, 1999) disorder. Because of the difficulty in applying the unwieldy diagnostic criteria in primary care practice, Escobar et al. (1989) devised an abridged somatization construct, called a Somatic Symptom Index (SSI), requiring only four symptoms for males and six for females to reach diagnostic significance. When the full criteria are not met for SD, patients with multiple unexplained somatic complaints lasting at least 6 months are usually given the diagnosis undifferentiated somatoform disorder. This classification may include such entities as fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, and others. DSM-IV criteria were designed primarily for adult populations, but may have applicability to child and adolescent patients.
Freud's first patients were somatizers. As a clinical neurologist beginning practice, his patients comprised essentially other physicians’ failures, not dissimilar to what is experienced by new young physicians today. His meticulous study of his patients’ symptoms and histories culminated in his theories of psychoanalysis, the significance 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 his 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, deprivation, and rejection.
Various descriptions of SD rely on psychodynamic principles to understand the symptom profile and the behavior of patients so diagnosed. Treatment may depend upon whether that conceptualization focuses on developmental failure, disturbances in the infant–mother or infant–caretaker relationship, affective deficits, alexithymia, object relations problems, homeostasis disruption, selectively learned dysfunction, or faulty developmental regulation (Knapp, 1989). Emphasis on learned behaviors may lead more commonly to cognitive-behavioral or group interventions, while other conceptualizations may encourage more relational, interpersonal, or psychodynamic approaches. Psychopharmacological approaches may be independent 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 indicate that the best therapeutic achievements, as modest as they may be, are the result of an ongoing empathic relationship with a consistent caregiver. Research on interventions with SD patients is hampered by a variety of problems: patients are usually seen in primary care settings, where therapists may be poorly prepared to work with demanding, frustrating patients; comorbid physical disease often is a major confounder. Studies have shown a 60% comorbidity with medical disease, 55–94% with depression, 26–45% with panic disorder, and 17–31% with alcohol abuse or dependence in SD patients (Bass and Murphy, 1991); and there is a relatively high rate of personality disorder in patients with SD, the most frequent types being avoidant, paranoid, and self-defeating, not borderline or histrionic as previous observers have reported (Rost et al., 1992).
Counteracting the prevailing rather nihilistic attitude about treatment of SD, one study showed improvement over a period 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’ consisting of individual psychotherapy, assertiveness training, problem-solving training, progressive muscle relaxation, and ‘other cognitive-behavioral, emotional and movement therapies.’ Patients showing most improvement had fewer symptoms and less psychiatric comorbidity.
It is generally acknowledged that to treat effectively patients with SD, primary physicians must be recruited as participants. A groundbreaking controlled study by Smith et al. (1986) demonstrated the effectiveness of a ‘consultation letter’ to primary physicians instructing them on a few key management techniques to use with their 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 no adequately controlled studies of psychotherapeutic intervention existed prior to the study by Smith and colleagues, a number of studies of undifferentiated forms of somatoform disorder suggest therapeutic benefits from an accepting attitude in the therapist (Rost et al., 1994), cautious efforts to shift 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 cognitive-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; Guthrie et al., 1993; Payne and Blanchard, 1995; Speckens et al., 1995). More recently, brief psychodynamic therapy of unexplained somatic symptoms proved superior in both controlled randomized and uncontrolled studies (Nielsen et al., 1988) compared with regular medical treatment alone. An uncontrolled intensive inpatient treatment program for chronic severe somatizing patients described a 33% improvement rate in 92 patients treated with combinations of relaxation training, physical activation, and pharmacotherapy (Shorter et al., 1992).
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; rigidity of adherence to belief in the presence of physical disease; high and usually inappropriate utilization of medical resources; unresponsiveness to pharmacologic treatment trials; alexithymia; risk of ‘occult’ comorbidities; sensitivity to rejection; and frequent dysfunctional patient–physician relationships. Such a context represents a profound challenge to the most well-intentioned, dedicated physician. With this realization, first attempts at establishing a therapeutic setting must begin with a caring rather than curing orientation, one that conveys acceptance, sincerity, and flexibility to the patient.
Therapeutic ‘triumphs’ may be measured in reduced overutilization of resources, limitations on unrealistic expectations, a commitment to a single primary care physician, and minimalization of ‘furor therapeuticus’ that may result in useless procedures, tests, and surgeries. The physician must be prepared for a long-term commitment to patients with SD. Restraint must be exercised in the urge to refer for specialist consultation, unless there is reasonable evidence to suggest specific comorbid conditions and thorough preparation of the patient for such referral. Wishful expectations in findings and outcome should 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 protracted process that, if pushed too abruptly, may mistakenly convey to the patient the physician's distrust, disbelief, or outright rejection of the patient's complaints. Families of patients with SD commonly have already registered disbelief in the patient's illness, perhaps even accusing them of malingering; the advocacy of the physician in such circumstances becomes an even more essential ingredient for management.
Some of the elements of CBT may be incorporated conveniently into the primary care physician's treatment strategy. For example, diary-keeping by the patient, activity prescriptions such as exercise and yoga, and ancillary ‘somatic’ treatments such as acupuncture, relaxation, 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 variety of side-effects that usually accompany trials of any new drug. Adhering to the low- or no-drug treatment approach may be difficult for the physician, but in time can demonstrate to the patient greater interest in the patient herself, with a deflection of exclusive focus on the symptom(s) alone. The presence of well-defined comorbid states such 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 appropriate, beneficial and less costly use of health resources.
The following case vignette illustrates a supportive, psychodynamic approach.
Mrs N's first visit as a new patient to a medical clinic was at the age of 45 with a complaint of varicose veins, 4 years after a hysterectomy in another hospital, where she had been seen for many years with multiple physical complaints. In this first visit she revealed that her husband had died 2 years before her hysterectomy and her 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 veins, adhesions, and scar reconstruction. Her medical record noted many visits to specialty clinics as well as the emergency room for a variety of major and minor complaints. In Skin Clinic alone, she was treated for eczema, varicose dermatitis, fibrous polyp of the vulva, contact dermatitis of the ears, seborrheic dermatitis, and contact neurodermatitis. She had had several minor accidents, dental problems and repeatedly lost her eyeglasses. It was not until 12 years later that ‘emotional difficulty’ was noted in her chart when she was seen in Neurology Clinic with ‘intense pain that could not be accounted for on the basis of her vascular disease.’ However, she was returned to Medical Clinic where she ‘complained excessively of joint pain’ thought by her doctor to be ‘out of proportion to physical findings.’ Finally, an entry of ‘neurasthenia’ was made in the record and she was referred for psychiatric evaluation. At first reluctant to see the psychiatrist, she ultimately accepted and in addition to current complaints she said that she had been sick ‘all my life’ but that things had gotten worse after her father died. She was now experiencing fatigue, abdominal and chest pain, and difficulty sleeping. She said she can usually ‘take things on the chin and come up fighting,’ but things had become more than she could 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 tried many drugs but they either did not help or she developed side-effects. Complaining of her prior treatment, she said that she could take better care of herself 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 fighting.’ 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 treatments to help; the physician expressed his 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, although she may be able to fight them to some degree. Because she always felt 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 who are unhappy and neglected, she was advised also to offer part-time volunteer work in a neighborhood nursing home, work that she found very satisfying (masochistic characteristics of her personality were constructively satisfied). Although symptoms did not remit, in time she reduced her visits to specialty clinics, discontinued her use of the emergency room, and began to talk more about her family relationships than her physical complaints. In time (that is, 2 years or a total of 24 half-hour visits), the patient requested lengthening the time between visits as she felt she was functioning better and wanted to ‘try it myself.’ Although this was granted, she was advised that she could always return to the old schedule if she felt it necessary, but that she did seem ready to use her own strong resources. Eventually she was seen every 4–6 months, with only an occasional phone call in between. She continued to see her primary doctor at 6-month intervals; this physician was given suggestions about how to work with a person with Mrs N's character traits and psychological defenses. He was encouraged to avoid the use of medications as she seemed to experience them as the physician's wish to be rid of her.
The following case vignette illustrates the application of CBT principles to SD.
Ms J, a 48-year-old female, raised in Mexico, with a very difficult and impoverished childhood, emigrated to the United States 6 years prior to treatment in search of a ‘better life,’ planning on earning enough money to return to Mexico and live more comfortably. Married at a very early age, and with three children, she had separated from her husband 1 year previously due to ‘domestic violence’ that had started early in the 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 multiple somatic symptoms. At the time of the referral, she was living with her oldest son, his wife, and children, serving as the children's caretaker. Symptoms included stomach aches, back pain, joint pain, arm pain, chest pain, headaches, menstrual irregularities, urinary pain and problems, burning in her genitals, vomiting, nausea, diarrhea, excess gas, difficulty digesting certain foods, difficulties with her sight and hearing, difficulties with balance, fatigue, throat pain/problems, and sexual dysfunction, all of them medically unexplained.
The psychologist's evaluation revealed that Ms J met full criteria for SD. She also had significant depression and anxiety symptoms. Therapy consisted of a 10-week CBT program at the primary care clinic 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 him 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 lowering stress levels as well as creating time for herself.
Because of her past history of abuse and deprivations, encouraging pleasurable activities as well as utilizing 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 form of distraction from her physical symptoms, allowing the accompanying relaxation to lower her stress levels and decrease physical symptoms.
Sleep hygiene was another focus of treatment. Ms J did not have a routine for sleeping. She complained of fatigue and awakening with bodily pain. Setting a routine of at least 7–8 hours of sleep 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 treatment was to challenge dysfunctional thoughts. Ms J's pessimistic outlook of her life included conviction that: her symptoms would never get better; she would die young; and she was a burden on her children (even though she helped them raise their own children by caring for them while the parents worked). By helping her look at her thought processes and teaching her the skills necessary to question and change them, she was able to decrease her symptoms and improve her quality of life. This included assertiveness training to address her inability to express her own needs and her low self-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 sleep routine and engage in pleasurable activity to help maintain the acquired behavioral and cognitive techniques that had significantly decreased her physical symptoms, including cessation of headaches and leg pains.
Clinical descriptions of hypochondriasis today are impressively consistent with those of earliest times and have been distilled and formalized in DSM-IV as follows: preoccupation with fears 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 appropriate medical evaluation and reassurance; the belief is not of delusional intensity and is not restricted to a circumscribed concern about appearance; the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; the preoccupation is not better accounted for by generalized anxiety disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder.
While there is general agreement that hypochondriasis is a ‘mental’ disorder categorically distinct from others, some subscribe to a dimensional concept in which hypochondriacal symptoms exist on a continuum from heightened awareness of bodily function to extreme delusional bodily preoccupation. Some consider distinctions between health anxiety, disease phobia, and disease conviction (Barsky and Wyshak, 1989); panic (Furer et al., 1997); a variant of obsessive-compulsive disorder (OCD) (Hollender, 1993) or a personality disorder (Tyrer et al., 1990). Psychoanalytic concepts are retained in the view that hypochondriasis is a defensive reaction against the guilt of aggressive impulses and overwhelming fear of ‘annihilation’ (Vaillant, 1977; Lipsitt, 2001a).
As with other somatoform disorders, clinicians who subscribe to the conceptualization of hypochondriasis as a learned behavior will lean towards CBT approaches, while believers in the primacy of developmental, interpersonal, or character structure as explanations of hypochondriasis will favor psychoanalytic/psychodynamic approaches. Differentiating the disorder as primary or secondary will influence treatment (Speckens, 2001), especially with a preference for psychopharmacologic treatment for accompanying diagnoses of anxiety or affective disorders. In spite of a wide choice of therapies, controlled studies showing therapeutic superiority of one over another have been rare.
There has been a paucity of controlled studies of the treatment of hypochondriasis, but past reports of several case series of cognitive-behavioral psychotherapy had suggested benefits (Kellner, 1982; Salkovskis and Warwick, 1986; Warwick, 1989; Logsdail et al., 1991; Visser and Bouman, 1992). Kellner's study demonstrated improvement in 36 patients with behavioral interventions that corrected misinformation and distortions and demonstrated to patients how these factors contributed to misattribution and persistent fearful beliefs.
More recently, several controlled studies have confirmed the earlier suggestions of the effectiveness of cognitive-behavioral 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 syndromes. In this survey, CBT-treated patients improved significantly more than control subjects in 71% of studies, with a trend of improvement in an additional 11% of studies. In one such controlled study, hypochondriacal 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 improvement, sustained in 3-month follow-up (Warwick et al., 1996). This finding has been replicated in other randomized controlled trials (Speckens et al., 1995). One such study (Clark et al., 1998) compared treatment of 48 patients with cognitive therapy to behavioral stress management and a no-treatment wait-list control group. Both therapeutic groups were effective, maintaining improvement after 1 year, with cognitive treatment showing more improvement in hypochondriacal 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 ‘significant beneficial effects’ at one year follow-up with CBT. The distinction in many studies between cognitive and behavioral treatment is not always clear.
One study (Bouman and Visser, 1998) evaluated the effectiveness of ‘pure’ time-limited cognitive or behavioral interventions in 17 patients in 12 one-hour sessions. Patients in both treatment groups showed equivalent improvement over controls on specific measures of hypochondriasis and depression. However, nonspecific factors such as patient motivation, therapist attitudes, and the therapeutic relationship could not be ruled out as contributing factors (studies of these important nonspecific dimensions of treatment in somatizing disorders are conspicuously lacking in the research literature). Treatment preference by patients may also influence outcome (J. Walker et al., 1999).
Group therapy using cognitive-educational 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 dysphoric mood and wellbeing. A study of 96 patients receiving combined individual and group ‘intensive’ inpatient CBT showed ‘substantial improvements or recovery’ from hypochondriacal symptomatology (Hiller et al., 2002). Predictors of poor outcome and course of illness were higher degree of pretreatment hypochondriasis, more somatized symptoms and general psychopathology (as measured on Symptom Checklist-90R), greater dysfunctional cognition, higher levels of psychosocial disability, and more extensive utilization of healthcare resources. Treatment was administered on a daily basis individually and in groups according to a therapy manual (Rief and Hiller, 1998). Goals of treatment were defined according to customary CBT principles: identification and modification of dysfunctional perceptions and thoughts; improved interpersonal and occupational function; and decreased dependency on healthcare resources. Educational and explanatory interventions, physical exercise, assertiveness training, progressive relaxation, and biofeedback were included in the manualized treatment.
Most studies involve patients already utilizing either mental or physical healthcare systems and not the community at large. In order to tap this resource and to assess effectiveness of interventions on ‘lower-level’ hypochondriasis, one study invited, by advertisement, ‘participants’ to apply for an ‘educational course’ called ‘Coping with Illness Anxiety’ (Bouman, 2002). Six 2-hour sessions, each dedicated to specific themes about hypochondriasis, were held for 21 participants in four groups of five to six, facilitated (not ‘treated’) by two graduate students of clinical psychology trained in individual cognitive-behavioral techniques, using a detailed manual. Parameters for hypochondriasis and depression (on selected pre- and posttest measures) showed improvement at 4 weeks and 6 months following the ‘course,’ suggesting that this is an acceptable, effective, and probably low-cost way to reduce hypochondriacal psychopathology, potentially applicable to nonhospital, nonclinic general medical practice. Other uncontrolled studies have shown benefits of brief explanatory therapy (Kellner, 1986; Barsky et al., 1988; Avia 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 confirmed the benefits of explanatory therapy on helping patients ‘maintain control’ of symptoms but with little change in symptomatology (Fava et al., 2000). Exposure, imaginal, and response-prevention therapies are also said to help correct misinformation or misperception, but no controlled studies are reported (Logsdail et al., 1991; Sisti, 1997).
Very few psychoanalytic studies exist. One Spanish study reports effectiveness of group psychoanalytic treatment (Garcia Campayo and Sanz Carrillo, 2000). The few reports on psychodynamic or psychoanalytic treatment of hypochondriasis generally warn of the negative consequences of ‘uncovering’ or ‘interpretive’ therapies that have a high risk of promoting ‘quasi autistic withdrawal,’ ‘tormenting self-observation’, and other regressive behaviors (Nissen, 2000). This is not to say that psychoanalytic and psychodynamic precepts do not have applicability in establishing and enhancing appropriate therapeutic relationships and treatment approaches in the management of hypochondriacal patients (Lipsitt, 2001a,b).
The role of reassurance in hypochondriasis has been a controversial one. While DSM-IV has made inability to reassure hypochondriacal patients a criterion of diagnosis, virtually all therapy reports include reassurance as one of many interventions. The ease with which somatizers can successfully be reassured varies with the chronicity and intensity of symptoms, personality variables in the patient, attitudes, and treatment style of the therapist (Kathol, 1997). Starcevic has provided a thoughtful and comprehensive overview of the varieties, pitfalls, and uses of reassurance in the treatment of hypochondriasis (Moene et al., 2000; Starcevic, 2001). Reassurance is regarded by cognitive-behavior therapists as a safety behavior for patients that interferes with progress and therefore should be avoided.
Although there have been suggestive case series reports that pharmacotherapy may be helpful in some cases of hypochondriasis (Fallon, 2001), there are insufficient controls to suggest that drug treatment has any significant advantage over long-term supportive therapy. It would appear that psychotherapeutic interventions work in the context of an interested, accepting, and concerned relationship. Suggestions for enhancing this relationship are similar to those for managing SD. However, most hypochondriacal patients do not manifest the same intensity or demandingness seen in patients with SD. Some may even respond to judicious attempts at reassurance. If hypochondriacal 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.
Patients rarely appear with ‘pure’ forms of hypochondriasis but may present with hypochondriacal reactions to established physical disease. For example:
A 58-year-old married woman with an obsessive-compulsive personality style, following a mild myocardial infarction, became hypochondriacally preoccupied with every minor physical sensation, certain that it was evidence of a fatal outcome. Accompanying depression was successfully treated with antidepressants, but fearful reaction to physical symptoms was chronically unreassureable. The patient 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 reports. In each session, she anxiously reviewed medication directions to be sure she was meticulously following medical orders. By the end of a year, she was able to be more flexible and less fearful, with little insight but increasing trust in the reassuring comments of psychiatrist and cardiologist, who coordinated their treatment.
In other approaches, cognitive-behavioral techniques show promise of hastening improvement. The following case vignette illustrates a CBT approach to treating combined hypochondriasis and abridged somatization.
Ms E is a 44-year-old married former history teacher who stopped working to care for her son and ailing mother. Five years previously, she presented with symptoms of chest pain and heart palpitations which, she feared, indicated cardiovascular disease. A cardiologist found no organic pathology and prescribed alprazolam, which 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, describing severe headaches of several months’ duration and worry that she had a brain tumor. Her physician had been trained in identifying somatization, and with Ms E could identify several recent ‘stressors’ in her life. He referred her for a stress management program, being careful to schedule a follow-up appointment with himself. Ms E hesitantly accepted and scheduled an appointment for the following week with a psychologist who worked in her primary physician's practice.
A diagnostic evaluation included questionnaires to assess her psychological health. The evaluation revealed that Ms E met criteria for abridged somatization and hypochondriasis. She reported a history of irregular and painful menstruation, diarrhea, abdominal bloating, as well as the chest pain, palpitations, and headaches described earlier, that remained medically unexplained. For the next week, the patient was asked to complete a daily diary recording the type and severity of physical discomfort, recorded as very high (average daily diary score = 3.0 on a 1–5-point Likert scale). She also endorsed significant hypochondriacal beliefs (Whiteley Index = 11), and anxiety symptoms (Beck Anxiety Inventory score = 21).
Ms E began a 10-session CBT. Although she expressed doubts about the potential benefits of this treatment, she agreed ‘to give it a try.’ Treatment began by teaching her to monitor her physical symptoms and related thoughts and emotions. She quickly recognized that she often experienced headaches and chest pain after difficult interactions with her son and mother. She was instructed in the daily practice of progressive muscle relaxation and diaphragmatic breathing. Over time, she began taking three relaxation breaks per day in order to eliminate muscular tension and to soothe herself. She also began to use relaxation techniques when she felt angry at her son or mother.
The next focus of treatment was teaching Ms E sleep hygiene 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 end of the day, she experienced early insomnia (at least 1 hour) every night. She used her relaxation skills just prior to bedtime. After a few weeks, on most nights she began falling asleep within 30 minutes.
Ms E's daily activities were also addressed. Spending her days working so hard to take care of her son, mother, and doing the housework, she was too tired to do anything in the evenings except rest on the couch. She and her therapist ‘problem-solved’ about reducing her responsibilities and increasing her pleasurable activities. The advantages and disadvantages of enrolling her mother in a day treatment program were reviewed with Ms E, after which she decided the potential benefits outweighed the costs. Once she had freed up a part of each day, she began taking increasingly long walks with a friend in the afternoons. Also, she and her husband began scheduling a night out once every week.
At the sixth session, Ms E and her therapist began discussing some of her hypochondriacal beliefs. She learned to look for evidence supporting and contradicting her beliefs about having cardiovascular 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 could remind herself that her physicians had found no sign of organic pathology. Learning to create the symptoms on her own by running up a staircase to create palpitations and grinding her 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 prevention plan. She agreed to continue using each of her newly acquired skills, i.e., relaxation exercises, engaging in pleasurable activities/exercise, sleep hygiene, 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 exams helped remind her that she was physically healthy. At the final session with the therapist, Ms E reported significant improvement in her headaches and chest pain. Her posttreatment questionnaires showed improvements in her daily diary scores (average = 1.3 on a 1–5 point Likert scale), hypochondriacal beliefs (Whiteley Index = 5), and anxiety (Beck Anxiety Inventory score = 10).
A final report to Ms E's primary physician described her progress and encouraged him to continue seeing her every 2 months for brief physical exams and to discuss her relapse prevention plan with her.
This particular somatizing condition has only recently (American Psychiatric Association, 1987) been included under the rubric of somatoform disorders and is usually considered a subtype of hypochondriasis because of the presence of intense fear of and belief in bodily defect, usually experienced subjectively as ugliness. It is defined as a distressing preoccupation with imagined defects of appearance or excessive concern over minor physical anomalies, unaccounted for by other mental disorders. Complaints may focus on the head and face, but may involve any part of the body. With onset in adolescence, many adults seek ‘corrective’ surgery from plastic surgeons and dermatologists (Phillips, 1996).
Poorly understood, it had previously been considered a delusional aspect of other psychiatric disorders. Psychodynamic authors have ascribed it to a defense against more overwhelming anxiety, with displacement from other emotional concerns to dissatisfaction with appearance or body configuration (Fisher, 1986). Others consider early experience and learning of greatest importance in affecting self-image, self-esteem, and bodily self-approval (Phillips, 1996). More contemporary thought regards dysmorphophobia as part of a physiological spectrum disorder that includes eating disorders, affective disorders, and OCD (Hollander et al., 1992), with its manifestation a function of culture 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).
Until recently, treatment recommendations were fairly pessimistic, with major intervention consisting of warnings to cosmetic surgeons to screen carefully patients requesting surgery for body changes, keeping in mind the fairly high incidence of disappointment with outcomes (Phillips et al., 2001). While early case reports indicated successful outcomes with exposure, systematic desensitization, self-confrontation, and response prevention, more recent therapeutic trials have stressed the promise of CBT (Cororve and Gleaves, 2001). An open case series of patients treated in small groups with CBT for 12 weekly 90-minute sessions, showed significant improvement in both body dysmorphic disorder (BDD) and depressive symptoms (Wilhelm et al., 1999). A 2-year follow-up of behaviorally treated patients followed with 6-month maintenance programs prevented symptom relapse and assisted in patient self-management of lapses typically associated with BDD (McKay, 1999).
A randomized trial of CBT combined with exposure and response prevention in 35 women for eight 2-hour sessions found significant improvement in self-image, self-esteem, and psychological distress compared with the untreated wait-list control group (Rosen et al., 1995). Another study (Veale et al., 1996) of 19 patients randomly assigned to CBT or wait-list control group for 12 weeks showed significant improvement (77%) on specific measures of BDD and depressed mood. BDD patients were found to be different from those with ‘real’ disfigurement who sought cosmetic surgery or were emotionally well-adjusted, as well as from healthy controls without defect.
Studies have noted that BDD 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 depression, 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-compulsive symptoms, although BDD showed greater improvement in depression and anxiety. It was concluded that BDD can respond to intensive, multimodal treatment. CBT, with or without medication, appears to be favored as the treatment of choice for BDD.
The importance of establishing a good therapeutic alliance has special salience with BDD patients as they are often reluctant to accept psychiatric or psychological care, being strongly attached to the idea that their ‘defects’ require surgical or medical ‘correction.’ History-taking should follow the usual recommendations for somatizing patients, with special attention to questions about self-image, self-esteem, previous forms of help-seeking, experience with surgical or dermatologic treatment, age of onset, avoidance of occupational or social situations or personal/sexual relationships (because of self-consciousness), and levels of perceived distress. Special attention must be paid to comorbidities of anxiety and/or depression, as it has been reported that as many as 29% of BDD patients attempt suicide (especially women concerned about perceived facial defects). In the context of a therapeutic relationship, SSRIs appear to be the first line of treatment, but require doses in excess of those for treatment of depression (e.g., fluoxetine 40–80 mg/day and fluvoxamine 200–300 mg/day). Concurrent CBT is recommended, including exposure and desensitization techniques, imagery, and self-confrontation. Long-term maintenance on therapeutic level doses of medication is advised because of high incidence of relapse. Meetings with family members, spouse, or significant others can help inform, educate, and provide understanding supportive assistance for the patient.
Clinical interest in hysteria very likely set the stage for subsequent psychoanalytic thought, for of all the somatizing disorders, it was clearly the one most associated with psychological conflict. 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, aphonia, deafness, convulsions (pseudoseizures), or tremors. Of patients entering a clinical setting with complaints of motor disability and diagnosed conversion disorder, 33% may be expected to have other Axis I diagnoses, and 50% Axis II diagnoses (Binzer et al., 1997). Characteristics of ‘la belle indifference’ (bland emotional reaction to presence of otherwise alarming symptoms), hysterical or histrionic personality and secondary gain, often associated in older literature with conversion disorder, appear to have no predictive diagnostic significance. Physical illness and conversion disorder are not mutually exclusive.
In addition to the psychoanalytic model of conversion alluded to above, others have suggested physiological and behavioral models. The neurophysiological conceptualization proposes an inherent defect in poorly identified brain functions, especially of the dominant hemisphere (Drake, 1993), interfering with verbal associations, while the behavioral theory suggests faulty childhood learning, with the child exercising learned helplessness utilized for secondary gain and control of interpersonal relationships (Barr and Abernathy, 1977). The psychoanalytic theory, on the other hand, describes symptoms as compromise formations with primary gain of conflict resolution through partial expression of the conflict without conscious awareness of its significance (Barsky, 1995).
Some have suggested a strong relationship between childhood traumatization by sexual or physical abuse and a later propensity for conversion disorder (Roelofs et al., 2002). However, one study of 30 patients with motor conversion disorder, with high degrees of parental rejection and low levels of affection and warmth as perceived by the patients, did not confirm an association of childhood physical and/or sexual abuse with conversion disorder (Binzer and Eisemann, 1998).
Although a variety 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 conversion symptoms reported unusual and unexpected responses in 16 patients during hypnosis (Moene and Hoogduin, 1999). While raising caution about this intervention, the authors also suggest that such events may offer opportunities to help patients enhance understanding and gain better control over symptoms. One of few randomized controlled trials (Moene et al., 2002), treating 45 inpatients comprehensively with symptom-oriented as well as expression- and insight-oriented techniques, found significant improvement in all subjects, whether hypnosis was used or not. Furthermore, hypnotizability was not predictive of treatment outcome.
A retrospective case series of eight children ages 9–18 with conversion disorder involving motor disturbance of gait, treated with inpatient behavioral management using a reward system, reported that all patients attained normal gait and improved activities of daily living (Gooch et al., 1997). To maintain improvement after discharge, instruction of the patient and family in pain and stress management appeared essential. Lacking controlled trials, other case reports include effectiveness of negative reinforcement (Campo and Negrini, 2000), culturally-relevant (shamanistic) treatment (Razali, 1999) showing the benefits of ‘indigenous psychotherapy,’ and rehabilitative inpatient treatment (Watanabe et al., 1998) using functional and behavioral therapies and extensive psychosocial support to produce rapid improvement in hysterical hemiparesis (mean length of stay 11 days). One study of psychological defense constellations comparing 19 patients diagnosed with conversion disorder to 32 healthy nonpatients showed nonpatients better able to perceive and express affective response to a stimulus picture, supporting the psychoanalytic hypothesis that conversion symptoms are nonverbal communications replacing perception and verbal expression of emotion (Sundbom et al., 1999). A recent report highlights the benefits of a multidimensional treatment approach that utilizes inpatient, partial hospitalization, and outpatient treatment employing psychodynamic, behavioral, psychosocial, hypnotic, pharmacologic, and culture- and religion-focused techniques (Schwartz et al., 2001).
To test the clinical theory that conversion disorder is promoted or perpetuated through questioning by parents and physicians, one study compared the interrogative suggestibility of 12 patients diagnosed with conversion disorder with a matched group with confirmed neurological disease, concluding that interrogative suggestibility was of no significant importance in the etiology of conversion disorder (Foong et al., 1997). Clinicians often caution that conversion disorder sometimes reveals subsequent organic disease in long-term follow-up. To assess this potential, 73 patients with medically unexplained motor symptoms were assessed and followed for 6 years, with only three patients manifesting new organic neurological disorders, in contrast to the 1965 classic study of Slater and Glithero (1965) showing 50% new neurological or psychiatric disorders in 10 years (Crimlisk et al., 1998). Others have also confirmed a decrease in percentage of patients initially diagnosed with conversion disorder who later are identified as having an organic (neurological) disorder (Mace and Trimble, 1996; Moene et al., 2000). Long-term chronic patients were at risk to develop SD in the absence of diagnosis of another disease.
Without adequate controlled studies providing evidence-based direction, treatment choice will depend largely on therapist preference and experience. The usual caveats on history-taking prevail, with special attention to history of trauma, sexual and physical abuse, and family history of conversion symptoms. Physical examination must pay particular attention to ruling out neurological diseases, such as multiple sclerosis and other peripheral and central nervous system disorders. Routine laboratory studies are indicated as well as EEG (to distinguish between epilepsy and pseudoseizures) and other special studies (e.g., MRI, X-rays, spinal tap, etc.) to rule out possible organic etiology. Many conversion syndromes will remit spontaneously with understanding and support, but early intervention can forestall potential chronicity and development of entrenched SD. Once chronicity has developed, intensive treatment may make use of all treatment modalities, including hospitalization, individual or group therapy, insight-oriented therapies, behavioral techniques, negative reinforcement, hypnosis, sodium amytal interview, physical therapy, biofeedback, relaxation training, and medication (primarily for comorbid anxiety, depression or other somatoform disorders). The therapeutic value of a trusting ongoing relationship is illustrated in the following case:
A 54-year-old married man was being treated pharmacologically and monitored monthly with supportive half-hour visits for chronic recurring depression. One day he paid a rare visit to his hated mother residing in a nursing home following a serious stroke. He found himself physically distressed in her presence, with nausea and a concern he might vomit and hastily had to leave. One day later he developed a left-sided hemiparesis. 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 consultation-liaison psychiatrist based in a general hospital, obtained the minimum essential tests and consults to rule out bona fide neurological disease. The therapist interpreted the completely normal studies to the patient, not that ‘nothing was the matter,’ but rather that ‘the tests are reassuring that this is a completely reversible illness.’ Because of the therapist's acquaintance with hospital medical and nursing staff, arrangements could be made by a team effort for a brief medical hospitalization for this patient, during which time he was treated very much as a true stroke patient would be, with rehabilitation, physical therapy, respiratory therapy, and the like. Within approximately 3 weeks, with virtually no psychotherapeutic intervention except regular supportive visits by his therapist, his illness had completely and ‘miraculously’ remitted, with neither physical residual nor understanding by him of how his feelings about his mother may have influenced his physical response. His 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 divulge or explore early contributing conflicts or experience. This may have to wait on a comforting/comfortable, trusting and safe relationship before there can be progress, especially true for children and adolescents where the support and participation of family, teachers, and physicians may be required in a team effort; often the pediatrician, with psychiatric or psychological backup consultation, may be the best option to assume the role of therapist. Any implication of malingering will be very counterproductive. Accompanying comorbid depression, anxiety, and behavior problems may respond to accepted pharmacologic ministrations. Use of hypnotic or narcoleptic techniques, if utilized, must be tentatively offered to patients whose fear of passivity or loss of control may induce overwhelming anxiety. Behavioral interventions should focus on improving self-esteem, capacity for emotional expression and assertiveness, and ability to communicate comfortably with others.
Originally known only by its most extreme clinical presentation in Munchausen's syndrome, the category of factitious disorders has only recently (and perhaps arguably) been included in the domain of somatoform disorders (DSM-IV).
Clinical presentations meet diagnostic criteria for factitious disorder if they: (1) intentionally feign physical or psychological signs and symptoms; (2) appear motivated only to assume the sick role; and (3) reveal no incentives characteristic of malingering. Psychological and physical signs and symptoms may present separately or in combination. Patients are often very intelligent, with a good grasp of medical knowledge and language, and frequently occupied in some aspect of medicine or related fields. They are persuasive and ‘creative’ in their 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 hospitalizations, frequently in various locations (‘peregrinating’), and may display multiple surgical scars (establishing the ‘veracity’ of their stories). Presentations may be of actual self-induced symptoms, of factitious medical history, embellishment of naturally-occurring anatomical anomalies, or the offering of (usually forged) documentation of previous treatment. They are generally very receptive (unlike malingerers) 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. Rarely will patients with physical factitia accept referral for psychiatric treatment.
Understanding why anyone would 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 accompanies fear of real illness with repetitive reenactment of the child's ‘doctor game,’ playing both active and passive sexualized roles as victim (masochistic) and victimizer (sadistic). Others hold that it is a manifestation of borderline personality disorder in which identity problems and conflicts over control and authority 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 history 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, albeit in faulty ways. The idea that patients are merely seeking attention seems unconvincing as there are so many other ways to behaviorally satisfy this wish (Lipsitt, 1982). Factitious illness by proxy invokes similar explanations in a mother (rarely a father) who vicariously fulfills psychological needs through illness perpetrated on a child.
The paucity of reliable findings in factitious illness arises from the elusiveness of these patients as well as their fabricated histories. Furthermore, their inability to form genuine relationships with staff and physicians who are often biased and resent patients’ deception reduces opportunities for meaningful cooperative study. In this context, it is not surprising that no controlled studies exist and it would appear unlikely that they will be possible in the future. Reports of therapeutic trials consist almost entirely of individual case reports (Fras and Coughlin, 1971; Earle and Folks, 1986; Merrin et al., 1986), some of which report variable success with treatment. In one reported series of 24 patients, 10 agreed to engage in psychodynamic psychotherapy for up to 4 years, with ‘favorable progress,’ according to the author (Plassman, 1994). Another treatment effort was reported to have modified reliance on the sick role in two patients in an inpatient behaviorally oriented program designed to avoid confrontation (Solyom and Solyom, 1990).
For reasons stated above, difficulty in forming an alliance with factitious patients is a major impediment to treatment. Early distinction between malingering and factitia may be possible if the seeking of secondary gain in the former is detectable. Willingness to undergo risky or painful procedures is more apparent in factitious disorder. Occasionally, it is possible, especially with the less severe cases, to establish a relationship that facilitates gathering a more or less accurate history and making a psychiatric referral for continuing management. If there is a hint of a therapeutic alliance, one may try to interest the patient in explanations of illness as related to stress or to help find alternative ways other than the sick role to obtain gratification. Early detection is encouraged by verifying elements of history either by noting inconsistencies in early background or by checking with other sources regarding previous hospitalizations and treatments. This latter endeavor, when exercised without the patient's consent, raises ethical questions without decisive answers. Laboratory studies can help to rule out impostured diseases.
Customary medical treatment is necessary for any self-induced pathological conditions. Working with hospital staff to control impulses of angry retribution may help to gain patients’ trust and confidence, in anticipation of further contact. Direct or especially insensitive confrontation of deception in these patients usually results in heated denial, outbursts of rage, or elopement, with potential further regressive and self-destructive behavior. If attempted treatment intervention is successful, it will likely be for the long term. Collaborative care between psychiatrist or psychologist and primary care physician may have more long-term success in containing factitious patients than psychotherapy alone, in hopes that the patient may ultimately accept and develop a trusting relationship with a primary physician. Pharmacotherapy can be offered for accompanying comorbid Axis I disorders. When factitious illness by proxy involves child abuse, it is essential to notify proper child care agencies. Offering protective care and perhaps therapy to the afflicted child and family therapy to the parents and child may be useful. It should be kept in mind that, although rare, factitious patients may occasionally launch malpractice suits (Lipsitt, 1986). Other isolated and occasional idiosyncratic interventions have been extensively reviewed elsewhere (Eisendrath, 2001). There are no controlled treatment studies.
Historically, the treatment of somatizing patients has been considered difficult and frustrating (Lipsitt, 1970, 1992). These patients tend to be dissatisfied with their medical care and may complain when their symptoms do not quickly resolve. Patients with multiple unexplained physical symptoms report high rates of disability. These patients also have a propensity for remaining idle, avoiding productive and 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 nine times the average of nonsomatizing patients (Smith et al., 1986; Barsky et al., 2001).
In our review of psychotherapy of somatoform disorders, it appears that available studies, both controlled and uncontrolled, fail to establish definitively any individual psychotherapy as clearly superior to any other. In this, there is confirmation of earlier reports of psychotherapy research (Bergin, 1971; Smith and Glass, 1977; Hartley, 1985; Lin et al., 1991). While case reports suggest that cognitive-behavioral approaches may be preferred in this era of urgent demand, reduced funding, and stringent regulations, adequate studies have yet to be performed that establish long-term benefits with this approach as superior to that of others. We are led to the conclusion that it is very likely that the ultimate efficacy of any therapeutic intervention with ‘difficult’ somatizing patients is realized as much (or more) through the nature of the patient–therapist relationship as through any other specific intervention. If this is indeed the case, then we must emphasize aspects of the therapeutic relationship that would appear to enhance an optimal outcome with this large group of patients. We therefore conclude with a summary of the challenges presented by patients who suffer from somatoform disorders and suggestions to deal with those challenges. Such an alliance will depend upon the respective contributions of patient and therapist to the relationship they establish between themselves.
Chronically somatizing patients approach each new 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 suffering. Building a trusting alliance in this context must begin with respect for the patient's symptoms and acknowledgment of their validity; a tolerance for repetition; an attitude of active, receptive listening; and a neutral approach that is neither dismissive, confrontational, nor overly reassuring. It is only with time, consistency, and continuing trustworthiness that a relationship will ripen into a trusting potentially therapeutic partnership. Promoting a certain level of dependence will fulfill a requirement for a ‘working alliance,’ while reminders to the patient of areas of strength, ‘survivorship,’ and courage will support optimal self-regard and autonomy while avoiding regressive tendencies.
The manner in which the clinician takes a history as part of a psychotherapeutic evaluation may pave the way for a therapeutic alliance. Somatizing patients come to a new encounter not only with a string of disappointments and thinly veiled anger, but also with a rich history of many previous encounters, multiple tests, and procedures (often redundant and without clear rationale). They are designated the ‘thick chart’ cases of medical practice. The prospect of reviewing 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 helpful to remind them that it is preferable to hear directly from the patient, to get a better sense of who that person really is, rather than read some impersonal remarks by others. Notations or forewarnings of ‘crocky patient’ (or other pejorative labelings) should be ignored in favor of the physician's own assessment of the patient's illness behavior and pattern of interacting. A good medical history should not be short-cut on the basis of preformed expectations. Attempts to hastily rush to psychological history-taking or ‘explanations’ will fall on deaf ears, as this is rarely the somatizing patient's language or conceptualization of illness. Likewise, premature reassurance, while seeming appropriate to the physician, may be perceived by the patient hungering for connectedness as the physician's disinterest or dismissiveness. The timing and degree of reassurance must be based on adequacy of data and the trust and security of the relationship.
Somatizing patients will be most ‘comfortable’ revealing historical details in physical or somatic terms, but this should not deter an exploration of significant events (e.g., losses, trauma, disappointments, deprivation, and so on) surrounding earliest onset of symptoms. However, patients who do not acknowledge, recognize, or describe emotional reactions (‘alexithymia’) may respond more readily to questions about ‘physical symptoms’ than about ‘depression’ or ‘grief’ as responses to stressful events. Some historical details may not be revealed until the patient feels assured that a trustworthy relationship exists; the more chronic and disappointing the patient's prior medical experience has been, the longer it will be before the patient reveals important historical information.
As the history evolves, attitudes, beliefs, and attributions may become clearer, as well as certain patterns of interaction and illness behavior, that is, the ways that the patient fulfills the ‘sick role.’ Distorted beliefs, contradictory ideas, and fears can be addressed at moments during the gathering of historical data when the patient appears receptive.
Because of the refractoriness of somatized symptoms to general interventions, physicians and therapists will be more successful with somatizing patients by adopting a ‘caring’ 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, heightening the would-be rescuer's frustration. Such frustration often fosters intensified efforts at (usually inappropriate) treatment, on the one hand, or specialty referral or dismissal on the other. Restraint in the use of medication is advised, although when positively indicated for comorbid affective and anxiety states, it is best administered with an expression of modest expectations.
Clear assignment of appointment times at fairly regular (but infrequent: approximately monthly) intervals is more effective than random appointments based on fluctuations in symptoms. Gentle limit-setting can be accomplished by spelling out a treatment plan from the beginning and then reminding the patient of the policy when ‘testing-out’ of the therapist's commitment occurs. In time, with increasing trust and comfort, the patient's repertoire will expand beyond the confines of symptom complaints. Inquiring about the ‘disappearing’ symptoms is unnecessary and may only suggest to the patient a greater interest in the patient's complaints than in his or her social world and family relationships.
When a solid working relationship is in evidence, therapists may fulfill their pedagogical function by explaining the causal connection between external stressors, physiological repercussions, and the experience of somatic symptoms. Although insight may be slow to develop, sufficient awareness of an emotional component may suffice to enhance receptivity to referral for specialized behavioral intervention. Discussion 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 successful, contact with the primary care physician should be maintained with the patient to avoid a sensitive reaction to intimations of rejection.
Whichever form of treatment the patient selects, it is likely that a good outcome will be greatly enhanced by a strong relationship of the patient with a primary care physician. Collaboration between the mental health professional and primary physician will strengthen the patient's belief and trust in the interest of his or her treaters. In this context, patients are likely to respond positively whether treatment is behaviorally, psychodynamically, or psychosocially oriented.
Drs Lesley Allen and Angelica Diaz-Martinez provided CBT clinical vignettes. Carole Berney, M.A., assisted with references. This work was supported in part by NIMH grant RO1 NH60265 (Dr Escobar).