Cognitive Behavioral Strategies for Somatization

1. Cognitive Behavioral Strategies for Somatization Alejandro Interian, Ph.D. Assistant Professor Department of Psychiatry

2. Defining Somatization • Presentation of physical symptoms that are: • unexplained after medical/physical examination (i.e., medically unexplained symptom). • associated with significant concern, distress or impairment • as a manifestation of psychological distress.

3. Latino-Somatization Connection? • There are a number of studies that report higher rates of somatic complaints among Latino respondent with major depression • In one example, the rates of somatization among females with major depression was (Escobar et al., 1987): • 58% of Puerto Ricans • 48% of Mexican-Americans • 19% of Non-Hispanic Whites • Culture is one aspect that guides the interpretation of symptoms

4. Somatization: Common across the board • In medical settings, approximately one-third of physical symptoms lack an adequate medical explanation even after diagnostic work-ups (Kroenke, 2003). • There is a clear association between levels somatic symptoms and levels of psychiatric distress (i.e., anx and dep; Simon et al., 1996) • This association is found worldwide and among all levels of education (though slightly strong among less educated individuals). • Somatic symptoms are the most common idiom of distress worldwide

5. Mind-Body Connection Somatization: REAL symptoms with emerging evidence of physiological pathways • Stress is associated with sympathetic nervous response, which includes increased heart-rate, breathing, and muscle tension. Also, includes diminished digestive functioning. • CHRONIC stress is associated with suppressed immune functioning, due to increased release of cortisol. • Brain-Gut Axis describes neural connections between the GI tract and the brain: • GI distress affect emotional centers of the brain and emotional (cognitive?) processing can affect GI functioning.

6. CBT for somatization: Assessment during therapy • What symptoms do they experience? How often? How painful? • What do they think to themselves when experiencing symptoms? • What do they do to try and cope with symptom? • What is their emotional reaction to the symptom? • Try to elicit variation • Are there times when their responses to the symptom are more mild? • Get a detailed sense of their involvement in daily activities. • Sleep patterns?

7. CBT for Somatization: Treatment Alliance • Reflection • Physical distress, Level of effort needed to cope, impact symptoms have had on their life • Validate their symptom experience • Avoid implying that symptoms are “not real,” exaggerated, etc. • For case presented: • Reflect her sense of needing help, the impact of her symptoms, etc. • What thoughts/feelings drives her need for help? • “You have told me about so many difficulties, the stressors, the pain. This has affected you to the point where you have thought about your funeral. At the same time, there is a part of you that is trying to get better because you are still in treatment, ________, and ____________.” • What are her concerns with the neurologists?

8. Mind-Body Connection CBT for Somatization: Presenting the treatment rationale • Symptom variation provides teaching moments. • “Goal of treatment is to figure out how you can control symptoms.” • Describe the potential for stress to affect symptoms. • Normal stress reaction in terms of sympathetic arousal—the body’s “emergency mode.” • For example, digestive functions are “turned off” when stressed. If prolonged, results in digestive distress (e.g., pain, constipation, diarrhea).

9. Behavioral Techniques • Increased Activity Involvement • Combats stress (minimize functioning in emergency mode) • Improves overall mood (as we see in dep treatment) • Provides Distraction from somatic symptoms • Pain perception has a subjective component—improved mood and distraction reduce the experience of pain • Exercise has physiological effects that combat somatization and stress • Do they get their daily dose of meaningful activity, productivity, and exercise?

10. Behavioral Techniques (cont’d) • Assertiveness Techniques • What kinds of needs are asserted? • What kinds of needs are not? • Do they engage in combative communication patterns? • Activity strategies and assertiveness help patients obtain reinforcement by behaviors other than illness behaviors.

11. Relaxation Techniques • Directly acts on physical symptoms, given its effects on breathing, heart rate, muscle tension, etc. • Patients report benefit soon upon learning the technique • Helps with stress management • Includes Diaphragmatic Breathing, Progressive Muscle Relaxation, Biofeedback • Practice, Practice, Practice. • Practiced in session with patient, consecutively for a period of weeks (combined with practice at home).

12. SleepStrategies • Establish consistent sleep patterns (same bedtime and waketime everyday) • Go to bed only when sleepy (stimulus control) • If not asleep within 20-30 minutes leave bed and return when sleep again (stimulus control) • Bed is only for sleep and sex. No TV, reading, etc. (stimulus control) • Comfortable sleep environment • Avoid alcohol/caffeine during 6 hours before bedtime • Exercise regularly, but not within 4 hours of bedtime Woolfolk and Allen (2007)

13. Cognitive Strategies • Much like CBT for depression • Looking for adaptability of thoughts • Eliminating distortions • Use somatic symptoms as anchors for examining thoughts • Look for variations in adaptability of thoughts and discuss their effect • Patients are likely to have difficulty identifying thoughts/emotions. • Likely to have schemas that include health concern