Academic journal article Journal of Cognitive Psychotherapy

Affective-Cognitive Behavioral Therapy for Somatization Disorder

Academic journal article Journal of Cognitive Psychotherapy

Affective-Cognitive Behavioral Therapy for Somatization Disorder

Article excerpt

Somatization disorder is the most severe and refractory of the somatoform disorders. In this article, we provide an overview of somatization disorder, reviewing both the experimental psychopathology and treatment outcome literatures. We also describe a new psychosocial intervention that we developed to treat somatization disorder, affective-cognitive behavioral therapy. We attempt to place the treatment within the context of contemporary cognitive behavioral therapy.

Keywords: somatization; psychotherapy; medically unexplained physical symptoms; psychosomatic; mind-body

Somatization disorder is the contemporary conceptualization of hysteria, a syndrome that has been observed since ancient times. According to the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV: American Psychiatric Association [APA], 1994), somatization disorder is characterized by a lifetime history of at least four unexplained pain complaints (e.g., in the back, chest, joints), two unexplained nonpain gastrointestinal complaints (e.g., nausea, bloating), one unexplained sexual symptom (e.g., sexual dysfunction, irregular menstruation), and one pseudoneurological symptom (e.g., seizures, paralysis, numbness). For a symptom to be counted toward the diagnosis of somatization disorder, its presence must be medically unexplained or its degree of severity be substantially disproportionate with any associated medical pathology. Also, to be counted toward the diagnosis each symptom must either prompt the seeking of medical care or interfere with the patient's functioning. At least some of the somatization symptoms must have occurred prior to age 30 (APA, 1994). The course of somatization disorder tends to be characterized by symptoms that wax and wane, remitting only to return later and/or be replaced by new unexplained physical symptoms. Thus, somatization disorder is a chronic, polysymptomatic disorder whose requisite symptoms need not be manifested concurrently.

The prevalence of somatization disorder in the general population has been estimated to be 0.1% to 0.7% (Faravelli et al., 1997; Robins & Reiger, 1991; Weissman, Myers, & Harding, 1978). For patients assessed in either primary care or specialty medical or psychiatric settings, the rate of somatization is higher than in the general population, with estimates ranging from 1.0% to 5.0% (Altamura et al., 1998; Fabrega, Mezzich, Jacob, & Ulrich, 1988; Fink, Steen Hansen, & Søndergaard, 2005; Gureje, Simon, Ustun, & Goldberg, 1997; Kirmayer & Robbins, 1991; Peveler, Kilkenny, & Kinmonth, 1997).

Although somatization disorder is classified as a categorically distinct disorder in DSM-IV, it has been argued that somatization disorder represents the extreme end of a somatization continuum (Escobar, Burnam, Karno, Forsythe, & Golding, 1987; Kroenke et al., 1997). Research suggests that the number of unexplained physical symptoms reported correlates positively with the patient's degree of emotional distress and functional impairment (Katon et al., 1991). A broadening of the somatization construct has been advocated by investigators wishing to underscore the fact that many patients are encumbered by unexplained symptoms that are not numerous enough to meet criteria for full somatization disorder (Escobar, Burnam, et al., 1987; Katon et al., 1991; Kroenke et al., 1997).

DSM-IV includes a residual diagnostic category for subthreshold somatization cases. Undifferentiated somatoform disorder is a diagnosis characterized by one or more medically unexplained physical symptom(s) lasting at least 6 months (APA, 1994). It has long been considered a category that is too broad because it includes patients with only one unexplained symptom as well as those with many unexplained symptoms. Undifferentiated somatoform disorder never has been well-validated or widely applied (Kroenke, Sharpe, & Sykes, 2007).

Two research teams have suggested categories for subthreshold somatization using criteria less restrictive and requiring less extensive symptomatology than the standards for DSM-IV's full somatization disorder. …

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