Category Archives: Somatization

Somatic symptoms

“When are somatic symptoms due to anger turned inward (repression) versus “sympathy symptoms”, expressions of guilt and sympathy with the loved other? Are the symptoms both an attack on the self and an expression of unconscious guilt? What is the best way to understand this issue of self-attack versus guilt as seen in somatic symptoms?” Thanks to Johannes for this great question!

Somatic symptoms can result from the discharge pattern of anxiety or the defense of somatization proper.

When somatic symptoms occur due to anxiety we see dizziness, ringing ears, blurry vision (cognitive/perceptual disruption), diarrhea, migraines, sudden need to go to the bathroom (smooth muscles), back pain, vulvadynia, tension headaches, clenched jaw (striated muscles).

In somatization, the patient feels rage toward someone, and then identifies with that person’s damaged body. For instance, a patient who wanted to stab her husband in the eyes suddenly had sharp pain in her eyes. A man who wanted to chop his father’s arms off suddenly lost sensation in his arms.

Repression is the resistance system by which the patient turns anger upon the self using defenses such as self-attack, character defenses, weepiness, conversion, AND identification with the object of the rage. Identifying with the damaged or murdered figure is a way to turn that rage upon the self and to punish oneself. Why? Because the patient not only feels rage but love and other mixed feelings for that person. So these “sympathy symptoms” are mobilized by love and guilt. Self-attack is always a way to punish oneself due to guilt over rage toward others, hurting ourselves to protect loved ones from our rage.

How do we know if somatic symptoms are due to anxiety or the defense of somatization? The symptoms resulting from somatization do not fit the symptoms of the pathways of anxiety, e.g., loss of sensation in the arms does not fit striated muscles, smooth muscles, or cognitive/perceptual disruption.

How do we know if somatic symptoms are psychological? When we explore feelings and anxiety rises, somatic symptoms will increase or emerge. If symptoms do not fluctuate with a rise and fall of unconscious feelings and anxiety, the symptoms most likely are not psychogenic and require more medical evaluation.

Is it a medical or a psychological condition?

“Sometimes patients believe their physical condition explains psychological symptoms such as depression or anxiety. The diagnosis can, e.g., be hypothyroidism. The patient then believes this is why she has been depressed, sad, without energy and joie de vivre. The physical diagnosis becomes used as another defense, making psychological treatment very difficult. How I can intervene with this type of patient?” Thanks to John Page for this question!

It is well known that people suffering from psychosomatic conditions often believe their problems are purely medical and not psychological. And, to be fair, this is sometimes the case. So we cannot be doctrinaire about this but must take a scientific approach to the problem.

When someone comes for a psychological assessment for a psychosomatic condition we cannot assume that his physical problems are psychological in origin. Instead, we have to explore and find out. Find a specific example where he has psychological problems and then explore his feelings.

As we explore feelings, feelings and anxiety will rise. If the patient’s symptoms emerge or worsen with a rise of feelings and anxiety, the symptoms have a psychological cause. If his symptoms do not emerge or worsen while feelings and anxiety rise, then we refer him back to the physician for further workup and medical evaluation.

Therapists often get into trouble trying to convince the patient that his symptoms are psychological in origin. In ISTDP we don’t do that. After all, we can’t know that in advance! Our job is not to convince a patient of anything, but to jointly explore and learn IF there is a psychological cause for his symptoms.

Pt: I don’t think there is any psychological cause for my problems.

Th: You may very well be right. There is no way for me to know that at this point. Could we explore a situation where you have some emotional conflicts so we can rule that out?

Pt: I don’t want to hear again that this is all in my head!

Th: Good, because it’s not all in your head. You are suffering genuine physical pain. The doctors sent you here so we can rule out whether there is a psychological cause. If we look at a situation where you have emotional conflicts, we can rule out this possibility and ensure you get the further evaluation you need. If there is any psychological element, you and I can eliminate that factor and, if there are still remaining symptoms, we can refer you back so you get the further evaluation and treatment you need. Does that sound like a reasonable plan for us to take?

Pt: Do you think this is all psychological doctor?

Th: I can’t make that assumption. This is too serious a problem for us to operate on the basis of guesses. What we can do, if you like, is do an assessment here so we get accurate information about what is causing your physical problems. If there is a psychological factor, we can remove it. If there is no psychological component, we can make sure the doctors focus on finding the medical cause instead. Shall we go ahead and find out together?

Avoid arguments with the patient over what is a scientific question. Then you will avoid will battles and misalliances. Your job is not to convince or argue with the patient, but to engage in scientific exploration of his feelings, anxiety, defenses, and symptoms. Together you can examine the pattern of responses that arise and jointly come to a conclusion based on the evidence of the session rather than on the basis of guesses or assumptions. If the patient makes his assumption and you make yours, you both make the same mistake: “Don’t confuse me with the facts. I’ve got an assumption going here!”