Chapter 36. Somatization Disorder and Undifferentiated Somatoform Disorder

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Mehmet E. Dokucu, C. Robert Cloninger: Chapter 36. Somatization Disorder and Undifferentiated Somatoform Disorder,

in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American

Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.259880. Printed 5/10/2009 from

www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VII. Somatoform and Factitious Disorders >

Chapter 36. Somatization Disorder and Undifferentiated Somatoform

Disorder

INTRODUCTION

Somatization disorder is among the best-validated disorders in psychiatry, but no specific

treatment is known for it. Moreover, the disorder leads to frequent and high-cost use of health care

services and often frustrates physicians and patients alike, resulting in therapeutic nihilism in the

minds of many people. The benefits of single treatment approaches (pharmacological or

psychosocial) reported by many controlled studies have been modest, and the clinical significance

of the reported benefits is not very impressive. It is therefore difficult to prescribe a precise and

strictly evidence-based treatment for somatization disorder and its less severe

versions—undifferentiated somatoform disorder and somatoform disorder not otherwise specified.

Nevertheless, our clinical experience and reports by others indicate it is possible to improve the

lives and functioning of patients greatly by following an individually tailored and multifaceted

management approach that incorporates biological, psychosocial, and spiritual approaches to

well-being. This means that for every individual patient, a practitioner should consider each of the

therapeutic modalities discussed here according to its suitability to the patient’s broad clinical

picture, the patient’s specific needs, and its availability in the patient’s community. For instance,

cognitive-behavioral therapy (CBT) groups that are modified for somatization may not be available

everywhere, or the clinician may not feel qualified to offer it in his or her office. Some patients may

not be interested in or adherent to exercise and/or medications. Thus, our general approach can be

summarized as being eclectic and customized to individual patients. We believe that because many

of the treatments studied show mild to moderate effect sizes, combining different modalities would

work additively or synergistically, improving functional outcome much more than a single modality.

In this chapter, when we do not provide specific references, this indicates that the material is

based on our clinical experience.

DIAGNOSIS AND TREATMENT ADHERENCE

The steps involved in developing an accurate diagnosis of somatization disorder are also a part of

its treatment because they involve the critical aspect of increased understanding of the patient and

his or her unique features. The process of reaching a well-documented diagnosis provides an

important opportunity for validation and reassurance and for building hope that culminates in a

strong therapeutic alliance and acceptance of help for the later stages of therapy.

An astute clinician would suspect the possibility of somatization disorder in a patient soon after the

initial encounter, yet several months may elapse until a definite diagnosis is formalized. During this

time, the physician should convey a sincere interest in the patient’s symptoms and suffering and

must assume a compassionate and hopeful stance. Many alternative medical and psychiatric

diagnoses must be carefully weighed. Telling patients that there is nothing wrong with them

physically and that their symptoms are produced “in their heads” would invariably lead them to go

“doctor shopping” and promote an unhealthy dualistic approach from the outset. After ruling out

other medical problems, a simple dialogue of “I have good news and bad news” is a good

alternative: The “good news” is that the patient does not have an acute, fatal, or degenerative

illness; the “bad news” is that the physician does not know for certain what is causing the

symptoms. In other words, the patient’s symptoms and suffering are real and the illness is well

recognized, but its etiology is complex. (Only later in the therapy do we tell the patient that he or

she has somatization disorder and discuss the diagnosis in detail; see “Treatment Goals,” later inPrint: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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this chapter). In this first phase of clinical management, a very detailed medical and psychosocial

history should be obtained and a thorough psychological profile generated. Somatization disorder is

very commonly associated with personality disorders (most commonly borderline and histrionic), so

patients usually have poor self-awareness. As a result, assessment of personality using a

questionnaire with internal validity controls, such as the Temperament and Character Inventory

(TCI; Cloninger et al. 1994) or the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway

and McKinley 1943), is frequently useful. In addition, with the patient’s permission, all available

medical records from previous contacts should be reviewed and collateral information from family

members and other treating physicians gathered. Patients’ perception of their problems is usually

narrow and cross-sectional. The process of gathering and organizing extensive lifetime data helps

the physician uncover information that the patient may not communicate because of limited

self-awareness. Taking the time to document patients’ past treatment experiences may also give

them a strong sense of validation as well as a feeling of being respected and cared for by the

clinician. They may even start to perceive a longitudinal pattern that they failed to see before. If

these steps are circumvented or abbreviated, patients will likely not respond to the reassurances

that they do not have some other illness because, as they might say, “You do not know me well

enough.” Putting in the extra time and effort will provide important leverage in the long term by

improving adherence with treatment and follow-up. In most of the cases, comprehensive

evaluations can be performed without invasive tests or exploratory surgery.

TREATMENT GOALS

Like many chronic disorders, somatization disorder is not curable with any known treatment

supported by randomized, controlled trials. Aiming for the complete resolution of all the symptoms

is an unrealistic short-term goal, even allowing for long-term hope of a full remission. A more

realistic initial set of goals would be reducing visits in which new symptoms are described, reducing

the number of unscheduled calls, decreasing the demands for referral to specialists, and reducing

requests for new medications and laboratory tests. Taking into account the well-established

phenomenon of alexithymia in somatization disorder (Bach and Bach 1996; Cox et al. 1994; De

Gucht 2003; Lesser et al. 1979; Subic-Wrana et al. 2005; Taylor et al. 1992; Waller and Scheidt

2004; Wise and Mann 1994), we think that, deep down, it is a form of impairment in

self-awareness. Patients with somatization disorder have speech patterns that reflect vague and

circumstantial thought processes. They have great difficulty understanding themselves, their

interpersonal relationships, or the associations among their many biopsychosocial issues. They

perceive life as chaotic, with unpredictable crises following one another. They perceive themselves

as confused victims, often of physical or sexual abuse. Without progress in these fundamental

aspects of the patient’s maturity, little improvement in well-being is possible beyond just managing

health care utilization. Hence, in the treatment of somatization disorder, the long-range goal should

be to improve self-awareness and to enable patients to enjoy their lives and to manage their lives

more effectively. Patients’ expectations of a passive cure are unrealistic and should be tempered by

the clinician. If a passive cure is implied by the physician or expected by the patient, both will be

frustrated. Alternatively, a more realistic and active cure would be the result of the patient’s

accepting the multifaceted nature of his or her problems and taking on many lifestyle-altering

responsibilities in addition to just being adherent to medications.

In the beginning, managing the illness and preventing iatrogenic harm should be a minimal first

goal. After a stable therapeutic alliance is established, the clinician can safely tell the patient that

his or her illness has been known for centuries, that it has a complex biopsychosocial etiology, and

that it is partially heritable. Explaining the complex nature of the etiology lays the foundation to

justify paying equal attention to the psychosocial, biological, and spiritual spheres of the patient’s

being. In other words, patients’ physical health must be objectively assessed. Their psychosocial

strengths and problems need to be evaluated and documented. Their spiritual history needs to be

assessed as well—that is, what circumstances trigger different attitudes and schemas, such as an

outlook of security and unity that leads to hope, love, and awareness or an outlook of separateness

and fear that leads to maladaptive desires and attachments, intolerance, hate, and cynicism.Print: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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Many patients are relieved when they are told that their disorder has been recognized by physicians

as a valid illness, that it has a name, and that it does not cause progressive physical deterioration

or death. However, this information alone will not satisfy the suffering patient if tangible progress

is not made toward the long-term goal of increased self-awareness and management of symptoms.

The measurable parameters for such a realistic long-term goal include improved social adjustment,

reduced symptom severity, prevention of iatrogenic harm, and reduced cost of medical treatment as

well as improvement in well-being. Well-being can be measured by increases in positive emotions

and healthy character traits (Cloninger 2004).

GENERAL PRINCIPLES FOR COORDINATION OF CARE

A broad consensus in the management of somatization disorder supports designating the general

practitioner as the central coordinator of all the health care that the patient receives (Murphy 1982;

Scallet et al. 1976). In many cases, a primary care physician can be effective in managing a patient

with the disorder without referrals to specialists—including psychiatrists. Of note, most patients

will resist a referral to a psychiatrist because they will perceive this as invalidation of their

symptoms and as a move toward termination of care by the provider. Emphasizing the role of the

psychiatrist as a consultant and ensuring the continuity of care by the primary physician help ease

this resistance. As such, the psychiatrist’s main role for many patients with somatization disorder

will be the treatment of comorbid psychiatric disorders such as depression, anxiety, or personality

disorder. A randomized, crossover educational intervention designed to provide the primary

physician with a psychiatric consultation letter reduced treatment expenses and hospitalizations by

half (Smith et al. 1986) and improved patients’ mental and physical functioning at follow-up (Rost

et al. 1994).

It is important to limit the number of physicians who treat the patients with somatization disorder.

All specialists should be informed of the diagnosis and should maintain regular communication with

the primary care physician. This minimizes the iatrogenic complications usually caused by

unneeded invasive tests or surgery. It also extends the care that the patient can receive in the long

run by decreasing health care costs. The patient should be seen by the primary care physician

frequently as an outpatient; the general rule is a visit every 4–6 weeks (Morrison 1979; Murphy

1982). The frequency of visits should be increased after acute episodes or during stressful times.

Patients are less likely to produce new symptoms to initiate visits when they already have regularly

scheduled visits. The visits should be brief and focus on the most pressing one or two problems.

More of the primary care physician’s attention should be paid to social and psychological problems

than to the physical complaints (Morrison 1979). The physical complaints should be acknowledged

in a nonreactive and calm manner. During visits, the primary care physician should regularly

perform a brief physical examination that at least targets the organ system generating the most

prominent complaint. The frequency of visits can be increased when the patient is experiencing

stressful life events, worsening symptoms, or comorbid psychiatric illness. The frequency of the

visits to the psychiatrist should be dictated by the complexity and treatment response of the

existing comorbid disorders. Any invasive tests should be based on objective criteria and the

clinical picture—not subjective complaints alone. Obviously, somatization disorder does not protect

patients from developing other disorders. Thus, regular physical examinations and prudently

chosen tests will serve to avoid errors of omission in addition to their psychotherapeutic value.

If the patient threatens to change physicians, usually because the current physician is not meeting

demands for certain medications or diagnostic tests, the physician should firmly and empathically

respond that this would be unfortunate in the long run because he or she knows the patient’s

history much better and thus can provide the optimal care. A complete physical examination and

routine laboratory screening performed biannually or annually may provide extra reassurance to

the patient.

In the following discussion we annotate more specific treatment modalities. Although we list them

as pharmacotherapy, physical therapies, psychosocial treatments, and treatments for well-being,

we do so solely to facilitate reading and not to imply that these divisions are real or thatPrint: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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psychosocial treatments do not change the body and vice versa.

PHARMACOTHERAPY

As a general rule, pharmacotherapy should be considered and initiated whenever there are

comorbid disorders, especially those of the depressive and anxiety spectrum, which are common in

patients with somatization disorder. Another common comorbid disorder that may respond to

pharmacotherapy is personality disorder (most commonly borderline and histrionic types; see

Chapters 53 and 54). There are no data that such treatment worsens the functional outcome of

somatization disorder. However, our clinical experience points to an important caveat: If and when

patients assume a passive and/or unrealistic stance toward medications, pharmacotherapy for

comorbid psychiatric disorder may actually prevent improvements in somatization while helping

with the comorbid psychiatric disorder. Thus, the clinician (the primary care provider or the

psychiatrist) should educate the patient about the limitations of medication treatment alone. Also,

in our clinical experience we have found this patient population to be extremely sensitive to the

adverse effects of medications, which makes pharmacotherapy doubly challenging for the

physician.

There are no published randomized, controlled trials of medications for the treatment of full

somatization disorder. There are, however, open-label studies showing effectiveness of nefazodone

(Menza et al. 2001) and gabapentin (Garcia-Campayo and Sanz-Carrillo 2001). There is a larger

body of literature studying pharmacological agents in patients who are classified under the rubric of

somatoform disorders, which is a term that may, in differing combinations, include undifferentiated

somatoform disorder or “functional somatic syndromes” (e.g., fibromyalgia, irritable bowel

syndrome, chronic fatigue syndrome, hypochondriasis, conversion disorder, pain disorder). These

studies, many of which were open label, have been reviewed (Fallon 2004; O’Malley et al. 1999),

and these reviews present a general consensus that antidepressant medications, especially of the

tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitor (SSRI) classes, are

superior to placebo and moderately ameliorate symptoms. O’Malley et al. (1999) found that TCAs

were somewhat more efficacious than SSRIs. Fallon (2004) reported that the treatment response of

patients with obsessive features was better than that of patients with pain and somatization. It is

still unclear what the mechanism of action is in the beneficial effects of medications: Do they cause

improvement by treating comorbid depression/anxiety or specifically target the unknown

etiopathogenesis of somatization disorder? First, with our current understanding of etiologies and

difficulty in diagnostic overlap, it is extremely challenging to design and conduct a study that would

satisfactorily answer this question. Second, somatization disorder patients without any other

psychiatric comorbidity are rare. Hence such a difficult and expensive study would not serve a large

population.

Antidepressants

In addition to treating comorbid depression and anxiety, antidepressants may target the

unexplained pain aspect of somatization disorder independent of the mood improvements.

Duloxetine, a new dual-action (serotonin and norepinephrine reuptake inhibition) antidepressant,

shows some promise in this respect. Although data for this drug in somatization disorder or less

severe forms are lacking, it has been reported to be efficacious in the treatment of “painful physical

symptoms” (such as back pain, abdominal pain, and musculoskeletal pain) in the context of major

depressive disorder (Brannan et al. 2005; Goldstein et al. 2004) and in the treatment of

fibromyalgia with or without major depressive disorder (Arnold et al. 2004) in multicenter

randomized controlled studies. St. John’s wort has been studied in depression with mixed results.

However, two groups reported efficacy of this herb in benefiting somatoform disorders (Muller et

1. 2004; Volz et al. 2002).

Mood Stabilizers and Anticonvulsants

Mood stabilizers have not been specifically studied in the treatment of somatization disorder.

Although its mood-stabilizing effect is questionable, gabapentin has been reported to benefitPrint: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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patients with somatization disorder in symptom improvement and global level of functioning in an

open-label study protocol (Garcia-Campayo and Sanz-Carrillo 2001). Mood stabilizers may be

particularly helpful in patients with prominent impulsive-aggressive behavior, but these patients

also may be treated with stimulants for persistent adult features of attention-deficit disorder

(Wender et al. 2001). Use of stimulants is limited, however, because of risk of abuse and

dependence.

Anxiolytics

Opipramol is an anxiolytic drug with structural similarities to imipramine. It is not available in the

United States but is widely prescribed in Europe for anxiety disorders. A multicenter randomized,

controlled study reported improvement over placebo in most criteria, including the main outcome

criterion: somatic subscore of the Hamilton Anxiety Scale (Volz et al. 2000). Due to lack of specific

data and potential cognitive and addictive issues, benzodiazepines should be used very sparingly

and for short-term management in coexisting anxiety that does not respond to other approaches.

Opioid Analgesics

Use of opioid analgesics in chronic nonmalignant pain is a subject of intense debate. We

recommend minimizing the prescription of these medications to patients with somatization disorder

in the light of patients’ quick development of tolerance and the drugs’ addictive properties and

adverse cognitive effects. When these agents are used, it is best to monitor patients closely and/or

obtain consultation from a pain specialist.

PHYSICAL THERAPIES

There are no published studies supporting exercise or physical therapy for the treatment of

somatization disorder. However, our clinical experience and indirect evidence from several

randomized, controlled trials for depression (Babyak et al. 2000; Dunn et al. 2005), chronic fatigue

syndrome (Whiting et al. 2001), and fibromyalgia (Glass et al. 2004; Gowans et al. 2004; Peters et

1. 2002; Richards and Scott 2002; Valim et al. 2003) suggest an adjunct role for regular exercise in

the management of somatoform disorders. In spite of an initial resistance to starting exercise,

patients usually report greater confidence in their bodies and reduced stress levels. Several case

studies and case series suggest that conversion symptoms of the disorder may benefit directly from

physiotherapy (Delargy et al. 1986; Heruti et al. 2002).

PSYCHOSOCIAL TREATMENTS

Earlier reviews of mostly uncontrolled treatment studies (Scallet et al. 1976) concluded that

specific psychotherapeutic approaches, including psychoanalysis, dynamically oriented

psychotherapy, behavior therapy, and group therapy, were not superior to eclectic psychotherapy

composed of social skills development, psychoeducation, reassurance, and redirection. Some

authors (Ford 1983; Kellner 1986) have suggested that insight-oriented and open-ended

psychoanalytical approaches are less effective than shorter-term CBTs.

To date, only one randomized, controlled trial has been published that investigated the effect of

psychotherapy in patients with DSM-defined somatization disorder (Kashner et al. 1995). This study

utilized a time-limited, short-term group psychotherapy that included psychoeducation. The study

sample was compared with patients whose primary care physicians received only a consultation

letter offering treatment recommendations for the disorder. Patients who received group therapy

showed greater improvement in mental health and physical functioning as well as requiring half the

health care costs. The goals of therapy were discussing and sharing coping strategies for

symptoms, understanding the benign nature of symptoms in addition to behavioral activation and

risk taking, engaging in structured problem solving, developing emotional expressivity and

perception, and building peer support.

Cognitive-Behavioral Therapy

The cognitive-behavioral model of somatization stresses the interplay of sensory physiology,

cognition, emotion, behavior, and environment. For instance, the patient’s heightened bodilyPrint: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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sensations may lead to increased emotional distress and avoidant behavior that may worsen the

physical symptoms (e.g., pain). In turn, the patient’s social circle (family, friends, physicians) may

reinforce the psychosomatic distress with their responses (Allen et al. 2002). Cognitive-behavioral

psychotherapy of somatic syndromes aims to facilitate the patients’ identification of their incorrect

beliefs about their symptoms and bodily functioning and identification of related

dysfunctional/avoidant behaviors, challenge these beliefs and behaviors, and eventually replace

the beliefs and behaviors with more adaptive ones. Authors who focus on the cognitive component

exclude behavioral techniques such as pain management, pursuing avoided activities, and

relaxation. Most treatment trials have included a combination of behavioral and cognitive

components. Sharpe et al. (1992) described practice-oriented cognitive-behavioral techniques for

somatization in more detail.

Thirty-one trials (29 randomized) utilizing cognitive-behavioral approaches were reviewed critically

(Kroenke and Swindle 2000), which led to a recommendation of CBT as a first-line treatment. In

71% of these trials, significantly more improvement was observed in the physical symptoms of

treatment subjects than in control subjects. In contrast to symptom severity, functional status of

patients was improved in only 26% of the trials. The authors’ meta-analysis suggested most of the

benefits were obtained independent of the reduction in psychological distress. This review included

trials with patients who had only one somatic symptom. None of the trials used the full

somatization disorder criteria. CBT interventions included both individual and group formats.

More recently, Allen et al. (2002) critically reviewed and meta-analyzed the Kashner et al. (1995)

trial and 33 others that recruited “polysymptomatic somatizers” (i.e., patients with non-DSM

somatization, irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome) and utilized a

variety of psychosocial modalities (including behavioral therapy, CBT, relaxation, and hypnosis).

Among variables such as patient’s diagnosis (chronic fatigue vs. irritable bowel vs. fibromyalgia vs.

somatization), type of treatment (CBT vs. relaxation vs. exercise), or format of treatment (group

1. individual), none showed significant association with the treatment outcome. The study

concluded that “the majority of studies provide some benefit” (mean effect size, 0.68) but criticized

most of the treatments for paucity of intent-to-treat analyses, lack of focus on functional outcome,

and short-term assessment of data (74% of studies). The authors’ approach of pooling

polysymptomatic functional somatic syndrome trials and somatization disorder trials is

controversial. Nevertheless, clinical similarities abound among these diagnostic entities, whereas

their boundaries are unclear (Nimnuan et al. 2001; Wessely and White 2004; Wessely et al. 1999).

Marital and Family Counseling

It is valuable to sustain contact with the patients’ family members. Because patients have low

self-awareness, they are not accurate in their descriptions of history, signs, and behaviors.

Collateral information obtained from others involved with the patients on a daily basis can be

crucial in understanding what really is happening. Permission from the patient must be obtained in

order to respect his or her rights of privacy, but the access to collateral information is worth the

challenge of maintaining confidentiality. Families respond well to information about the illness and

psychoeducation regarding behavioral pitfalls and strategies. Families can provide help in

maintaining adherence to therapies and alert the physician to doctor shopping, medication abuse,

or social problems. In the course of such interactions, if significant relationship difficulties or poor

communication in the marriage or family structures is observed, more formal marital or family

counseling should be recommended.

In essence, we believe that most psychosocial interventions achieve benefits in reducing symptom

severity that are statistically significant but modest in effect size. None of the interventions is

clearly superior to the others, and there is an overall lack of clinically significant and long-lasting

improvement in functional outcome for the majority of patients. Therefore, we recommend that the

clinician combine multiple treatment modalities on a case-by-case basis to obtain an additive or

(possibly) synergistic response. Furthermore, he or she should consider adding the well-being

treatments described in the next section in order to enhance the long-term response andPrint: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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self-reliance of the patients.

TREATMENTS FOR WELL-BEING

We have summarized the current state of knowledge in the basic management of somatization

disorder. What is most needed now in the treatment of the disorder is a clinical description of how

to facilitate radical transformations that improve self-awareness and enhance well-being. Radical

transformations refers to changes in character that are large and stable and that indicate a

fundamental change in self-understanding, goals, and values. Treatments that focus on enhancing

well-being and self-awareness appear to be crucial for treatment of chronic and recurrent mental

disorders such as recurrent mood disorders and generalized anxiety disorder (Fava et al. 1998,

2005; Ma and Teasdale 2004; Teasdale et al. 2000, 2002). The key elements of treatment needed to

produce large and sustained character developments have been described in part elsewhere

(Cloninger 2004). In the following discussion we point out elements of promising treatment

approaches that merit systematic clinical trials based on our positive clinical experience with these

approaches in patients with somatization disorder.

The personality traits and chaotic lifestyles of patients with somatization disorder can make the

establishment of a trusted helping alliance difficult. Nevertheless, crises and problems do occur for

which patients have a genuine motivation to obtain help, and they usually do have maximum

thoughts and relationships that are amenable to psychotherapy. (Maximum thoughts are those that

one considers most insightful and creative, as opposed to minimum thoughts, which involve basic

functions such as “I am hungry.” Maximum relationships are those that provide the highest level of

satisfaction; minimum relationships are those with people at the margins of one’s life. See

Cloninger 2004 for a detailed description.) Hence, the therapist must be patient and ready to

provide appropriate service and thereby to establish the beginnings of a working relationship with

trust, hope, and compassion. Change in personality is stepwise, and the steps are small and

influenced in a nonlinear manner by the working alliance and its context. As an adjunct to the

principles of effective treatment already described, some additional mental exercises can be helpful

in enhancing therapy.

First, individuals with somatization disorder have shallow thinking. Shallow thinking involves

impairments in monitoring thoughts or the thinking process and has been variously described as

deficits in superego functions or low levels of the five aspects of self-transcendence (Cloninger

2004). In our experience, these deficiencies in self-transcendence can be improved by a simple

exercise to awaken the patients’ physical and intuitive senses that we call the “union in nature”

meditation. It is a stepwise awakening of the senses of touch, taste, smell, hearing, and vision. The

physical and intuitive senses of people are often partially asleep (i.e., outside of self-aware

consciousness) when they are in distress and conflict, which is frequent in individuals with

somatization disorder. For example, individual differences in the sexual aspect of

self-transcendence (measured as the tendency toward repression rather than sensory responsivity)

are expected to influence sensitivity to touch. In fact, repressive personality style was correlated

moderately with the length of sensory stimulation to elicit awareness of touch sensations (Shevrin

et al. 2002). In other words, less transcendent individuals take longer to become aware of sensory

stimulation. Individuals high in the sexual aspect of self-transcendence recognize the beauty and

meaning in sensory experiences intuitively, whereas those who are low in this function are

alexithymic. Scores on the Toronto Alexithymia Scale were moderately correlated with low scores

on all three TCI character scales, and the strongest correlation was between the scores on the TCI

Self-Transcendence subscale for sensibility and the Toronto Alexithymia Scale subscale for

externally oriented thinking (r = –0.4; P < 0.0001) in a sample of 644 individuals from the general

population (Cloninger 2004). These relationships are clinically relevant to people with somatization

disorder, who often have alexithymia and comorbid personality disorders.

The union in nature exercise is described in depth elsewhere (Cloninger 2004). It takes about half

an hour and is enjoyable. It appeals to nearly everyone, including sensation-seeking narcissists

who want to be keenly aware of their environment. It should be begun early in therapy. ThisPrint: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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meditation is simple to explain and do, but it can have profound effects even at an early point in

therapy when insight-oriented discussion and reflection are ineffective or even counterproductive.

At this early point it may be useful to combine the regular practice of union in nature with the

experience of artistic creations that inspire joy (hereafter termed elevated artistic creations). As an

example in harmonious music (as opposed to music that includes much dissonance), the works of

composers such as Bach, Mozart, and Schubert often elevate mood, attention, and integrated

thinking regardless of debates about the explanatory mechanisms underlying these effects (Bodner

et al. 2001; Campbell 1995, 1997; Chabris 1999; Thompson et al. 2001; Twomey and Esgate 2002).

Benefits can also be obtained from other kinds of artistic creation and from the inspiring writings of

highly coherent philosophers listed and described elsewhere (Cloninger 2004).

An important clinical caveat should be mentioned about experiencing elevated artistic creations.

When people who have been highly repressed (i.e., are poor in listening to their psyche) begin

meditating and experiencing elevated creations, they may experience anxiety and other resurgent

emotions such as those described by the writer Stendhal while viewing inspiring art in Florence.

Patients should be advised simply to interrupt the exercise temporarily if they become disturbed.

They should be reassured that their experience is a part of the process of increasing

self-awareness. They can be taught simple relaxation exercises and learn to titrate their own

reawakening by combining relaxation with meditation. Learning to remain calm and to focus on

understanding what is happening is an important step in the development of greater self-aware

consciousness.

Another specific exercise can be introduced to help patients to be calm and let go of their struggles

with other people or themselves. This exercise is called the “silence of the mind” meditation and

has three phases that correspond to the three stages of self-aware consciousness: getting calm and

accepting, growing in awareness of one’s subconscious thoughts (i.e., mindfulness or meditation),

and contemplation (i.e., listening to the psyche effortlessly) (Cloninger 2004). Initially only the

first phase is taught, as a relaxation technique to be used when someone feels angry, is anxious, or

has other negative feelings. The full sequence is described elsewhere (Cloninger 2004). The silence

of mind meditation provides a nondemanding self-paced way by which a person can gradually grow

in self-acceptance, self-awareness, and well-being.

After patients have begun to be aware of their subconscious conflicts and have an interest in the

origins and consequences of those conflicts, further work can be done in a therapeutic alliance to

help them become more aware of the degree to which their behavior is reactive to conditioning and

hence not free, flexible, or voluntary. Initiative, self-efficacy, and industriousness can be developed

by individualized discussion of some of the powerful situations that trigger or maintain the patient’s

maladaptive behaviors. Simply being aware that such powerful situations exist and that they are

not an essential part of one’s own lifestyle is a major advance in self-understanding and often

reduces the influence of external controls, thereby helping the person become more self-directed.

It is important that patients recognize that the therapist regards them with respect for their human

dignity as free agents in search of understanding. Everyone wants to discover a way to live that

satisfies his or her basic needs for happiness, understanding, and love. Fundamental character

change only develops through voluntary self-directed choices in search of a way of living that is

satisfying and not self-defeating. Even when dealing with crises, it is useful for the therapist to help

the patient recognize general principles of coherent living that recur in many specific guises.

Toward this end, in addition to the meditation and contemplation methods just described, patients

are encouraged to let go of all struggles, such as fighting, judging, blaming, and criticizing of

oneself and others. They are encouraged to work in the service of others rather than being

preoccupied with self-gratification. Ultimately, psychotherapy is a path to well-being, not just a

technique for treating disease. An exclusive focus on disease or problems obscures the way to

radical transformation of character deficits. For example, consider a situation in which you are

bicycling down a mountain road and notice a rock on the path ahead. If you continue to focus on

the rock, you are likely to hit it. On the other hand, if you simply focus on where you want to go,Print: Chapter 36. Somatization Disorder and Undifferentiated Somato… http://www.psychiatryonline.com/popup.aspx?aID=259884&print=yes…

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then you will automatically ovoid the obstacle. Likewise, it is possible to help patients to recover

fully by facilitating growth in self-understanding, which leads to psychobiological integration

manifested by coherence of personality and remission of vulnerability to somatization, depression,

and anxiety.

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