Treating Somatization: A Cognitive-Behavioral Approach

Somatization is among the most puzzling phenomena that health care workers encounter. In a somatization disorder, the patient describes and experiences multiple physical symptoms in the absence of any identifiable physical causal mechanism. Somatization is universal. It has been described in all societies, both past and present. The patient who somatizes feels in great distress and is often dysfunctional. Somatizing patients incur large healthcare expenses and consume disproportionate amounts of time and energy of healthcare providers. In addition to the expensive direct costs of somatization, somatization disorder creates enormous indirect costs to the economy in the form of lost work productivity. On occasion, individuals diagnosed with somatization disorder report being bedridden for 2 to 7 days a month.

Robert L. Woolfolk, Ph.D., Professor of Psychology and Philosophy at Rutgers University and Visiting Professor of Psychology at Princeton, and Lesley A. Allen, Ph.D., a clinical psychologist and Associate Professor of Psychiatry at Robert Wood Johnson Medical School, have authored a lucidly written volume that presents a theory-based cognitive-behavioral framework for relieving the suffering in patients who have been diagnosed with somatization disorder. The authors first define the disorder in great detail. They describe the differing diagnostic classifications, which they use to explain and then to elaborate on their unique treatment model for this disabling psychiatric disorder. Drs. Woolfolk and Allen review the differing criteria for somatization disorder, which was first introduced in DSM-III. They follow the history of the nomenclature and diagnostic criteria for this disorder through DSM-III-R and DSM-IV. They take note of the World Health Organization’s (WHO) different set of diagnostic criteria offered in the ICD-10. They suggest that some of the differences in the diagnostic criteria of DSM-III, DSM-III-R, DSM-IV, and ICD-10, although sometimes subtle, may be responsible for some of the inconsistencies and divergent epidemiological findings with regard to this illness. Some epidemiological researchers have suggested that somatization disorder is relatively rare. The authors believe that the actual prevalence of somatization disorder may be substantially higher than the literature suggests for the following reasons. First, autobiographical memory of past psychiatric symptoms, including somatic symptoms, is unreliable. Individuals forget previously reported symptoms that are no longer troublesome. Second, the diagnosis of somatization disorder necessitates that a physical examination and diagnostic tests be performed or that past medical records be reviewed to determine the nature and longevity of each described symptom. Such extensive investigations of physical symptoms are too costly to incorporate into large epidemiological studies. Third, physicians are probably more likely to make the somatization diagnosis than non physician diagnosticians or epidemiologists. Non physicians conducted the epidemiological assessments without access to medical records in the Epidemiological Catchment Area study and the WHO studies, and they have underestimated the prevalence of this disease.

Drs. Woolfolk and Allen also discuss what they term subthreshold somatization. In this condition, patients are affected by unexplained symptoms not numerous enough to meet the criteria for full somatization disorder, and which cannot be explained after appropriate investigation. They also discuss what they term “functional somatic syndrome,” or, weeks of co-occurring symptoms that are currently medically unexplained, such as irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia. These entities are considered diagnosable medical syndromes by some, but according to these authors, may be variants of somatization disorder. In this chapter, the authors discuss the most commonly reported problem in pediatric care, recurrent abdominal pain, which they believe is equivalent to a somatization syndrome in children. They note that the juvenile somatization patient (who may describe symptoms that resemble fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome) functions poorly in school, overuses medical services, and may report high rates of emotional distress such as depression and anxiety. They comment that treatment for juvenile somatization has been examined in very few controlled studies. They suggest that a form of cognitive behavioral therapy for recurrent abdominal pain and chronic fatigue syndrome may be useful, as this therapy has two targets: to train children and/or adolescents in stress management techniques for their symptoms and to train their parents not to reinforce illness behavior.

After reviewing the history, epidemiology, and clinical characteristics of somatization disorder, Drs. Woolfolk and Allen provide a rationale for their innovative treatment approach and detail the process of diagnostic assessment, case formulation, and treatment implementation used in their clinic. They illustrate their approach with clinical examples and sample dialogues between patient and healthcare provider. They recognize that individuals who have been diagnosed with somatization disorder typically have had a history of mutually unsatisfying and unsuccessful involvement with physicians and mental health professionals. For that reason, they emphasize the clinician’s role in establishing and maintaining a long-term and strong therapeutic relationship with this diverse, and sometimes difficult, population.

Chapters 5 through 9 of the book describe the most current and comprehensive version of the authors’ psychotherapeutic program for patients who have been diagnosed with somatization disorder. They detail their 10-session regimen of a cognitive behavioral approach for these patients, which they have named affective cognitive behavioral therapy (ACBT). They note that their treatment paradigm for somatization is a work in progress. They comment that, as they wrote and re-wrote the text, over time they learned from their experience with regard to diagnosis and treatment, training, and collaboration with other healthcare providers (primary care doctors).

In Appendix A, they describe a 10-session standardized intervention that is comprised of a mix of relaxation training, behavior modification, cognitive restructuring, increasing emotional awareness, and interpersonal skills training. The program described is an abbreviated version of the longer intervention the authors pioneered in their clinic.

Appendix B provides the research-based evidence for the efficacy of their treatment regime. They describe the randomized controlled treatment trial used for 84 patients previously diagnosed with full somatization disorder; the patients were treated in either 1) the control intervention, augmented standard medical care, or 2) their 10-session ACBT paradigm combined with augmented standard medical care. In both groups, a letter was sent to the patients’ primary care physician. The letter stated that the patient met the DSM-IV criteria for a diagnosis of somatization disorder and provided four recommendations for ongoing treatment by a primary care physician: 1) schedule regular appointments every 4 to 6 weeks with the patient; 2) conduct a physical examination in the organ system relevant to the presenting complaint; 3) avoidance of unnecessary diagnostic procedures, invasive treatments, and hospitalizations; and 4) avoidance of disparaging statements such as, “Your symptoms are all in your head.”

The conduct of the study is described in great detail in Appendix B as well as the evidence of the success of the ACBT treatment.

Appendices C and D are two scales that the authors have used to measure somatic symptoms in their patient groups. These scales and accompanying scoring scales are valuable tools in the assessment of this particular patient population.

Appendix E contains detailed instructions for teaching patients progressive muscle relaxation, which would be beneficial to mental health practitioners who are unfamiliar with useful noninvasive treatment.

The therapeutic approach detailed by Drs. Woolfolk and Allen is innovative and derived from their clinical experience. The fundamentals of ACBT are presented in a clear, cohesive language. This would enable a novice to learn its fundamentals and apply them in clinical practice. The authors are optimistic about the treatment potential of their program for a group of patients who have long been regarded as untreatable by physicians and therapists. I would recommend this book to beginners and long-term practitioners—for the beginner it serves as an instructive manual; for the seasoned clinician, a refresher course.