Cognitive behavior therapy for somatization disorder: a preliminary investigation

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Abstract

Patients diagnosed with somatization disorder have high rates of disability and often prove refractory to treatment. This preliminary investigation examines the effect of a 10-session cognitive behavior therapy (CBT) protocol on the physical discomfort and disability of severely impaired somatizers. The severity of patients’ physical discomfort and disability was assessed at baseline, post-treatment, and eight months following treatment. Patients reported significant improvement in symptomatology and physical functioning between baseline and post-treatment as well as between baseline and follow-up. The findings suggest that CBT might benefit patients diagnosed with somatization disorder and should be subjected to a controlled treatment trial.

Introduction

Patients diagnosed with somatization disorder represent a formidable challenge for the healthcare system. As defined in DSM-IV, somatization disorder is a chronic, polysymptomatic disorder that is characterized by at least four unexplained pain symptoms, two unexplained gastrointestinal symptoms, one unexplained sexual symptom, and one pseudoneurological symptom (American Psychiatric Association, 1994). Patients diagnosed with somatization disorder are notoriously difficult to treat. They repeatedly seek treatment (Smith et al. (1986b), Speckens et al. (1995)), derive little benefit from treatment (Fink, 1992), and experience protracted impairment, often lasting many years (Coryell & Norten, 1981). These patients have been shown to incur 6 to 14 times per capita annual health care expense and are bedridden for 2 to 7 days each month (Smith, Monson, & Ray, 1986a; Katon et al., 1991).

To date, no psychotherapeutic nor pharmacological intervention has been found to produce clinically meaningful improvements in patients diagnosed with somatization disorder. Only one published study has assessed the efficacy of psychotherapy for such patients (Kashner, Rost, Cohen, Anderson, & Smith, 1995). Although statistically significant reductions in physical impairment were reported in this study, the question of therapy's efficacy is rendered uncertain due to rather spotty attendance at treatment sessions and the modest effect size (Kashner et al., 1995). The only other intervention, that has been tested in a controlled trial with these patients, is a psychiatric consultation letter written to patients’ primary physicians. Smith found this letter, which describes somatization disorder and provides recommendations for the conduct of primary care, to coincide with reductions in patients’ healthcare utilization (Smith, Monson, & Ray, 1986b). The investigators did not report whether patients who received this intervention experienced any improvements in their physical symptoms.

Cognitive behavioral interventions have shown some promise in treating patients with fewer and less chronic, unexplained physical symptoms. Examples of less severe conditions that appear to benefit from CBT include irritable bowel syndrome (Payne & Blanchard, 1995), chronic fatigue syndrome (Sharpe et al., 1996), and some cases of one or more unexplained physical symptoms (Speckens et al., 1995). Whether somatization disorder is as responsive to CBT as are these related conditions has yet to be examined.

A cognitive-behavioral conceptualization of somatization provides a rationale for treating this disorder with CBT. The model emphasizes the interaction of physiology, cognition, emotion, behavior, and environment (Sharpe, Peveler, & Mayou, 1992). Patients presenting with somatization seem to have higher levels of physiological arousal and to be less likely to habituate to a stressful task than control subjects (Rief, Show, & Fichter, 1998). This physiological arousal is compounded by a tendency to amplify somatosensory information; that is, these patients are hypersensitive to bodily sensations which are experienced as intense, noxious, and disturbing. (Barsky, 1992). Further, somatization patients have negative cognitions about their physical sensations (Rief, Hiller, & Margraf, 1998). For example, they may believe that pain, fatigue, and/or discomfort of any sort are signs of disease. In addition to misinterpreting somatic sensations, some patients catastrophize to the extent that they imagine repeated physical sensations are a sign of a fatal disease, such as cancer or AIDS. Thus, somatizers’ excessive physiological arousal produces physical sensations that are not only disturbing, but also frightening.

These cognitive distortions elicit negative emotions and maladaptive behaviors. Thoughts of possible illness give rise to feelings of anxiety and dysphoria which are likely to maintain physiological arousal and physical symptoms. Intending to prevent injury or exacerbation of symptoms, somatoform patients typically cope by withdrawing from activities (Smith et al., 1986a; Katon et al., 1991). Such time away from activities provides opportunities for additional attention to be focused upon one's physical health. Further, patients suffering from these physical symptoms, distorted cognitions, and negative affect may seek repeated physician visits and diagnostic assessments. Physicians, in turn, attempting to conduct thorough evaluations and avoid malpractice suits, may encourage somatizing behavior by ordering unnecessary diagnostic procedures. These tests, even if negative, reinforce somatizers’ maladaptive belief that any physical symptom indicates organic pathology. Also, unnecessary medical procedures may result in iatrogenic illness.

The suggestion in the aforementioned literature that CBT could prove efficacious in the treatment of unexplained physical symptoms, led us to design what is, to our knowledge, the first cognitive behavioral treatment protocol engineered specifically to treat somatization disorder. The aim of this pilot study was to investigate both the feasibility of treating somatization disorder with CBT and the effect of CBT on the physical symptoms and disability of a small group of these patients. This study would serve as the foundation from which a larger-scale randomized controlled treatment study could be conducted.

Section snippets

Study design

The study was conducted in the Department of Psychiatry at Robert Wood Johnson Medical School (RWJMS). Patients were referred to the study by physicians affiliated with RWJMS. All patients meeting DSM-IV criteria for somatization disorder were enrolled in the study and began the treatment. Patients were assessed one week prior to treatment (baseline), one week after treatment (post-treatment), and 8-months later (follow-up). Assessments of patients’ physical discomfort, physical functioning,

Results

Ten of the eleven patients completed all ten treatment sessions and the two post-treatment assessments. One participant withdrew after the fourth session and failed to complete post-treatment questionnaires. The one drop-out was younger (age=30) and had suffered with his symptoms for less time (duration of symptoms=5 years) than the treatment-completers.

Repeated-measures ANOVAs indicated that physical discomfort scores were reduced over time, as reported in the symptom diaries (F(2,18)=12.59, p

Discussion

The findings of this preliminary investigation suggest that CBT might produce lasting and clinically meaningful reductions in the physical discomfort and disability of patients diagnosed with somatization disorder. The improvements observed in study patients’ symptoms are especially noteworthy given that these patients had suffered with unexplained symptoms for over 18 years. While the benefits of CBT have been demonstrated with patients suffering from less severe and less chronic cases of

Acknowledgements

This research was supported in part by Grant No. 32-99 from the Foundation of the University of Medicine and Dentistry of New Jersey. The authors would like to thank Jonathon Feldman, Nick Giardino, Jumi Hayaki, Sherri Irvin, Elizabeth Pratt, Carolyn Rabin, Cameron Smyser, and James Williams for their contributions to the project.

References (29)

  • American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, (4th ed.) Washington,...
  • A.T. Beck et al.

    An inventory for measuring clinical anxietyPsychometric properties

    Journal of Consulting and Clinical Psychology

    (1988)
  • A.T. Beck et al.

    An inventory for measuring depression

    Archives of General Psychiatry

    (1961)
  • M.B. First et al.

    Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)

    (1997)
  • Cited by (0)

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