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Somatization: Diagnosing it sooner through emotion-focused interviewing



Anxiety in a patient with physical complaints should prompt an evaluation for somatization.
Somatization: Diagnosing it sooner
through emotion-focused interviewing
Allan Abbass, MD, FRCPC
Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
Applied Evidence
somatization, the translation of emotions into
somatic problems or complaints. It is well docu-
mented—though still largely unrecognized in
practice—that somatization accounts for a large
proportion of office visits to primary care physi-
cians as well as specialists,
leading to unnec-
essary testing, treatment, and hospitalization,
disability and corporate financial loss,
earlier mortality,
and frustration for patients
and physicians.
No longer a diagnosis of exclusion
Despite the burden somatization places on the
medical system, the diagnosis is often made by
indirect methods such as checklist, speculation,
or exclusion when other problems are ruled out.
The common position, even in recent reviews,
is that somatization should be treated by non-
specific measures, such as frequent office visits
to increase the patient’s and physician’s ability to
cope with what is often seen to be a chronic and
incurable disorder.
Such a position is no longer
Based on recent quantitative and extensive
case-based research, specific emotion-focused
brief therapies and videotape-based research have
clarified how emotions are experienced in the
body and how somatization of emotions occurs
(see The physiology of emotions). These meth-
ods, including short-term dynamic psychotherapy
(STDP) have been used to diagnose and treat
somatization effectively since the 1980s.
Somatization, with its morbidity and chronicity,
Practice recommendations
Obvious anxiety in a patient with physical
complaints should prompt an evaluation
for somatization.
Become familiar with the 4 patterns of
somatization and their manifestations.
Learn how to conduct an emotion-focused
interview, which, when applied appropriately,
will help rule somatization in or out.
42-year-old man has chronic fatigue and
fibromyalgia that has led to a 13-month
disability leave from work. The reason
for his current office visit is longstanding pain
in his shoulders. As you take his history, he is
sitting with hands clenched and he generally
appears tense.
A 38-year-old woman with severe incapacitat-
ing gastroesophageal reflux disease, irritable
bowel syndrome, and depression has been too dis-
abled to work for 2 years. At the time of your
interview, her posture is relaxed and she shows
no signs of anxiety.
These 2 very different patients (whose cases
I will review in detail) share a common problem:
Correspondence: Allan Abbass, MD, FRCPC, Associate
Professor and Director of Education, Psychiatry, Director,
Center for Emotions and Health, 8th Floor, Abbie J. Lane
Memorial Building, Halifax, NS B3H 2E2, Canada. E-mail:
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 231
232 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
need no longer be diagnosed by exclusion nor
treated palliatively without specific diagnostic
Videotaped case-series research shows 4 main
patterns of somatization: 1) striated muscle uncon-
scious anxiety, 2) smooth muscle tension 3) cogni-
tive-perceptual disruption, and 4) conversion.
Striated muscle tension due to unconscious
anxiety manifests through hand clenching, sigh-
ing, and even hyperventilation that the patient is
not aware of. These patients may report panic
attacks, chest pain, headache, fibromyalgia, and
other musculoskeletal complaints. These condi-
tions are often frustrating to family, employers,
and physicians since conditions like chronic pain
respond to treatment slowly or not at all.
Smooth muscle tension due to unconscious
anxiety causes acute or chronic spasm of blood ves-
sels, GI tract, airways, and the bladder. Patients
exhibiting smooth muscle tension may present with
GI symptoms, migraine, hypertension, urinary fre-
quency, and upper airway constriction mimicking
asthma. They often report histories of depression,
panic, substance abuse, personality disorders, and
past sexual or physical abuse.
Cognitive perceptual disruption due to uncon-
scious anxiety typically involves visual blurring,
tunnel vision, loss of train of thought, and “drift-
ing,” wherein the patient is temporarily mentally
absent from the room. These patients have
chronically poor memories and concentration.
They are commonly victims or perpetrators of
partner abuse, have frequent accidents, and have
transient paranoia. They often end up seeing
neurologists and undergoing expensive testing.
Most have histories of dissociative disorders,
personality disorders, or childhood abuse. In the
family doctor’s office they frequently forget what
was said and call back after the appointment.
They appear confused and easily flustered and
either avoid physical examinations entirely or
endure them with great anxiety.
The physiology of emotions
To diagnose and manage somatization we
must know how emotions are experienced
and how they may become somatized.
Davanloo discovered through studying sever-
al hundred case videotapes that specific
emotions manifest in specific ways regardless
of gender, age, or ethnicity.
This emotion
physiology constitutes a norm to compare
with a patient who somatizes emotions.
For example, rage is experienced as an
internal energy sensation, heat, or “volcano”
that rises from the lower abdomen to the
chest, neck, and finally to the hands with an
urge to grab and do some form of violence.
Guilt about rage is experienced with upper
chest constriction or even pain, intense
painful feeling with waves of tears and with
thoughts of remorse about experiencing the
When feelings are experienced con-
sciously, by definition they are not being som-
atized at that moment.
Why somatization occurs
When feelings are intense, frightening, or con-
flicted, they create anxiety and defense mech-
anisms to cover the anxiety (see the Figure on
page 234). If these feelings are unconscious to
the patient, the subsequent anxiety and
defenses may also be outside of awareness.
This is the finding common in people who
have been traumatized by someone close to
them: feelings of rage toward a loved one are
unacceptable, frightening, and avoided through
somatization and other defenses.
research has found that patients with hyperten-
sion, migraine, irritable bowel syndrome, and
other conditions internalize anger and thus
increase their somatic problems.
and inhibiting of emotions, including anger, is a
common finding in somatizing patients.
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 233
Major types of defense
Two important categories of defense include
isolation of affect and repression.
Isolation of affect is awareness of emotions in
one’s head without experiencing them in the body.
Intellectualization is a form of isolation of affect.
Repression is the unconscious process by
which emotions are shunted into the body rather
than reaching consciousness at all. For example,
strong emotions, including rage, may directly cause
sighing and a panic attack without the person being
aware of either the emotion or the sighing.
Experiencing the emotions
overcomes somatization
Videotaped research also shows that if a person
can experience true feelings in the moment,
somatization of these feelings is weakened and
overcome. The feelings being experienced push
out the anxiety and somatization (Figure). Thus,
somatization can be reduced or removed by help-
ing a patient feel emotions being stirred by recent
events or from past events. Through this process
Conversion manifests as muscle weakness or
paralysis in any voluntary muscle. Patients with
acute conversion describe dropping items or even
dropping to the floor as muscles give way without
explanation. They will often report histories of
witnessing or experiencing violent abuse.
One pattern usually predominates
The total amount of somatized emotion is dis-
tributed over the 4 pathways
(Table 1)
. One
pathway generally prevails at any given time,
though different pathways may come into play
as anxiety waxes or wanes. When anxiety is
expressed primarily through smooth muscle
tension, cognitive perceptual disruption, or con-
version, the striated muscles are relatively
This finding of apparent calm while somatiz-
ing has been noted elsewhere in research of
patients with hypertension.
This is the “belle
indifference” a patient expresses as they are tem-
porarily relieved of muscle tension through somati-
zation elsewhere.
Examples of diagnosable somatization patterns
Somatization Observations during emotion-focused Examples of related health
format diagnostic assessment complaints or health problems
Striated muscle Progression from hand clenching, arm Fibromyalgia, headache, muscle
tension tension, neck tension, sighing spasm, backache, chest pain,
respirations to whole-body tension shortness of breath, abdominal
(wall) pain, fatigue
Smooth muscle Relative absence of striated muscle Irritable bowel symptoms, abdominal
tension tension. Instead activation of smooth pain, nausea, bladder spasm,
muscles causes, for example, cramps in bronchospasm, coronary artery
the abdomen or heartburn. spasm, hypertension, migraine
Cognitive-perceptual Relative absence of striated muscle Visual blurring, blindness, mental
disruption tension. Instead patient loses track of confusion, memory loss, dizziness,
thoughts, becomes confused, gets weakness, pseudo-seizures,
blurry vision paresthesias, fainting, conversion
Conversion Relative absence of striated muscle Falling, aphonia, paralysis,
tension. Instead patient goes weak weakness
in some or all voluntary muscle
234 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
one may diagnose somatization and also produce
a therapeutic effect for a patient.
An objective assessment
Because the process of somatization is uncon-
scious to the patient, diagnosis is based on objec-
tive findings during examination rather than on a
patient’s report. This is similar to evaluating a
patient with abdominal pathology: we would not
expect the patient to report an abdominal mass,
even though we could detect it and train the
patient to palpate it. The somatizing patient
believes the problem is physical, so the history
reported is more likely to lead to physical testing
and medical treatments than to a direct examina-
tion of the emotional system. Although clues in
the history may suggest a patient is somatizing,
the definitive test, like that of an abdominal exam-
ination, is “hands on,” observing the patient’s
direct response to an emotion-focused interview.
Actively exploring emotions
Examination of the emotional system is analogous
to a physical examination of other systems, and
progresses from observation to “palpation” or
“percussion” (Table 2).
Observe the patient for visible unconscious
anxiety. Then, in the context of a supportive
patient-doctor relationship, explore emotionally
charged situations that generate symptoms.
Alternatively, one may ask in what way strong
emotions like anger affect the patient’s physical
problems. Asking about specific recent events and
feelings that were triggered usually mobilizes
emotions, giving you and the patient a direct look
at how emotions affect them physically.
If a patient is anxious in the office, it will be
most meaningful to examine the feelings they
experience during the interview.
Managing defenses
At times, the defenses used to avoid feelings must
be pointed out before the patient can see and
interrupt these behaviors. If the process is too
detached or intellectual, then feelings will not be
activated and the system cannot be assessed. The
physician’s rapport allows him or her to clarify the
process and the need for the patient to try to
approach and experience feelings when speaking
about them. This is analogous to the process of
Relationship between unconscious feelings, anxiety, and defenses
Unconscious feelings
Guilt about rage
Unconscious defenses
Isolation of affect
Repression of affect
Unconscious anxiety
Striated muscle tension
Smooth muscle tension
Cognitive-perceptual disruption
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 235
examining a sore abdomen when a patient is
guarding: the patient must relax for examination
to take place, and we help them do this by
explaining the process.
Patients who are defensive and insist the prob-
lem is not related to emotions are managed differ-
ently. These patients usually are quite tense and
already emotionally activated. An open examina-
tion of feelings the patient has about coming to see
you that day is a good way to begin. Through this
focus one can see the patient’s somatizing patterns
directly as well as develop a working rapport.
Managing anxiety
If the patient becomes anxious when asked about
emotions, introduce a calming step by asking the
patient to intellectualize about the specific bodily
anxiety symptoms. This reduces the anxiety by
using the defense of intellectualization.
Recap and planning
The interview is concluded by reviewing the
findings with the patient in the same way
one would share findings of a blood test.
Management options would depend on the find-
ings and may include another interview, further
medical investigations, referral for treatment,
or follow-up to gauge the patient’s response to
the interview itself.
With the focused assessment, the somatic
symptoms will transiently increase or decrease,
disappear, or not change at all (Table 3).
An increase in symptoms with emotional
focus suggests that emotions aggravate or
directly cause the problems. A decrease in
symptoms during the test also suggests a link-
age to emotions. Disappearance of the symp-
toms by bringing emotional experiences to
awareness is the best direct evidence that som-
atization of these emotions was causing the
patient’s symptoms.
No change in a patient’s symptoms or signs—
provided there was adequate emotional activa-
tion—suggests no somatization of emotions. In
these cases, other physical factors must be
sought. For example, a woman with chronic left
leg weakness and numbness had no shift in symp-
toms with this test: she was found to have neu-
ropathy due to multiple sclerosis. We have found
Exploring emotions in a patient-centered interview
Action Example
Observation Note any signs of unconscious tension, somatic distress, or
defensiveness from the start of the interview
Ask about emotions Can you describe a situation when the symptoms get worse?
What feelings do you have when you talk about that?
How do you experience the feeling of anger in your body when it is there?
Distinguish feelings from The tension you had was anxiety, but how did the anger feel?
anxiety or defenses Becoming quiet was what you did but how did you feel inside?
Observe physical Observe the physical and behavioral responses in the patient
responses when the emotional system is activated
Give feedback and plan Review all findings with the patient. Verify the patient agrees with
what you have observed. Plan any further treatments or referral
236 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
that 5% to 10% of patients referred to our diag-
nostic clinic have physical problems that were
mistaken for somatization.
False negatives
False negatives occur when the test does not
detect the process of somatization when it is pres-
ent. This will occur if the level of emotion mobi-
lized was too low, if the patient is too sedated, if
the defenses the patient used were not sufficient-
ly interrupted, or when the patient is not working
collaboratively with the doctor during the test. In
each case the patient must allow emotions to be
mobilized and the doctor must focus adequately
on the emotional experiences to yield an inter-
pretable response.
False positives
False positives occur when the patient has a
rise or fall in symptoms during the test for other
reasons—eg, coincidental shifts in episodic
conditions like muscle spasm or symptom
reduction due to distraction during the test
itself. It is important in these cases to repeat
the test more than once and see if the results
are reproducible.
STDP is clinically effective
for patients with somatization
Short-term dynamic psychotherapy (STDP)
formats specifically help a patient to examine
trauma and loss-related emotions that result in
somatization, depression, anxiety, and self-defeat-
ing behaviors. Case-series videotaped research
over the past 30 years has established the effec-
tiveness of the methods in both short and long
term follow-up.
STDP is efficacious in controlled trials
and meta-analyses
In 1995, Anderson and Lambert
conducted a
meta-analysis of 26 controlled studies and found
Interpretation of responses to emotionally focused assessment
Response Interpretation and action Beware of
Response 1: Symptoms go The diagnosis is likely False positives due to coincidental
up with emotional focus then somatization. Prescribe symptom changes in interview
down after focusing away emotion-focused psychotherapy
from emotions and monitor for gradual Health problems unrelated to the
symptom removal somatization could always be present
Response 2: Symptoms are The diagnosis is (was)
improved or removed by somatization of those
emotional focus or emotional emotions. Follow-up to see
experience in the office if gains are maintained
Response 3: No change in Somatization is unlikely to be the False negatives due to high defenses,
symptoms cause of the symptoms. Look for sedation, lack of cooperation,
physical causes. inadequate focus by physician
Response 4: Unclear May or may not be an emotion-
response based component in the symptoms.
Repeat test, consider other
diagnostic tests or referral for
emotion-focused diagnostic testing
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 237
STDP to be superior to minimal treatment con-
trols and wait lists including in samples with som-
atization. It was found to be as effective in remov-
ing anxiety and depressive symptoms as cognitive
behavioral therapy. A recent meta-analysis,
using more strict inclusion criteria, yielded the
same findings. In a recent randomized controlled
trial of symptomatic patients with personality dis-
orders, STDP brought significant symptom reduc-
tion while cognitive therapy did not, suggesting
that STDP may have added benefits in more
resistant and complex symptomatic patients.
In our current Cochrane review search,
have found 40 published randomized controlled
trials supporting its efficacy with a range of dis-
orders including ulcer disease, irritable bowel
syndrome, dyspepsia, and urethral syndrome.
Our review has likewise found STDP to be superi-
or to minimal treatment or waitlist controls and
that the gains are maintained in follow-up averag-
ing over 1 year.
STDP is cost-effective
and reduces health care utilization
STDP has been shown to reduce healthcare uti-
lization and to be cost-effective in treating
patients with dyspepsia, irritable bowel syn-
drome, depression, and self-harm and treatment-
resistant conditions.
Of specific cost figures
cited in reviewed papers, 27 out of 34 showed cost
savings with STDP including reduction in total
costs, medication costs, disability, hospital, and
physician use.
Case 1: Striated muscle anxiety
This 42-year-old man had chronic fatigue and
fibromyalgia which lead to a 13 month disability
up to the time of consultation. He came to the
office with longstanding pain in his shoulders.
His hands were clenched during the interview,
and he appeared tense while giving his history.
DOCTOR: Can you tell about a specific time when
you had an emotional upset so we can understand
how exactly it affects you?
ATIENT: Yeah, problems at home with my wife….
Saturday she wanted me to do some work on the
garage. She started to yell. Every day it’s the same
thing and I’m getting tired of it.…
OCTOR: So how do you feel toward her?
ATIENT: [Takes a deep sigh, hands become
clenched] Mad.
OCTOR: You mean mad … angry?
ATIENT:: Yeah.
OCTOR: How do you experience the anger inside
ATIENT: Very, very… tense
OCTOR: That is tension…anxiety?
OCTOR: How did you experience the anger?
ATIENT: I start to ignore her.
OCTOR: Is that a mechanism to deal with anger?
But how do you experience anger underneath?
ATIENT: It’s really hard to put a word on it…. I get
really’s like a rage.
OCTOR: So how do you experience the rage?
ATIENT: [Patient takes a big sigh and clenches his
hands tightly]
OCTOR: Do you notice you sigh and become tense
when you talk about the rage.
ATIENT: No, I didn’t. I don’t feel anxious.
OCTOR: But, do you notice the sigh and your
ATIENT: I do now, but didn’t see it before.
OCTOR: Is this what is happening to you … that
you are getting all tensed up about these feelings?
ATIENT: Yeah, it must be.
At a later point in the 1-hour session, the
patient was able to feel the visceral emotions of
rage, guilt about the rage, and sadness over sev-
eral years of conflict. When the feelings were
experienced in the office, he had an abrupt drop
in muscle tension and bodily pain: this was fur-
ther evidence he had been somatizing, or as he
said, “bottling up” these complex feelings.
As is typical of patients with primarily striat-
ed muscle anxiety, he denies being nervous
despite showing obvious anxiety in the inter-
view. He denies anxiety because it has been
unconscious to him, thus free to create
fibromyalgia pain. Through this single interview
a link is made for both patient and doctor
between blocked feelings and body pain. With
10 treatment sessions focused on this process, his
fibromyalgia resolved; he returned to work and no
longer needed antidepressants.
Case 2: Smooth muscle anxiety
This patient is a 38 year-old woman with severe
incapacitating GERD, irritable bowel syndrome,
and depression who was disabled from work for
2 years at the time of consultation. This woman
had a very relaxed posture with relaxed hands
and an absence of obvious anxiety. After 10 min-
utes of exploring situations and events that
make her stomach worse, we arrive at the
following point.
DOCTOR: Can you tell me about another time when
your stomach felt worse?
ATIENT: Yes. There was once when my sister-in-
law did something and it made me angry. Yeah,
when people make me angry I don’t tell them, I just
avoid them.
OCTOR: Can you describe one of those times, so
we can see how that affects you.
ATIENT: Once she was arguing with my brother,
like they usually do….
OCTOR: How did you feel then?
ATIENT: … Now I just got that again [pointing to her
stomach and chest with upward motion and burps]
OCTOR: Heartburn? Just came on?
ATIENT: Yeah, heartburn, just came on.
OCTOR: Is there anything else you notice? Like in
your stomach?
ATIENT: No, just that … but I can hear my stomach
OCTOR: So is it when you have anger your stom-
ach churns and you get this acid?
ATIENT: Must be….
OCTOR: ...because in your approach to talk about
anger you got cramps and acid. So is that one way
the anger goes?
ATIENT: Yes it must be, but I never thought of that
part. [Stomach stops churning and heartburn stops
as we talk about it for few minutes.] You know, this
all started to get worse when my fiancé dumped
me. [She goes onto describe a story of being not
only rejected but also feeling humiliated by how it
was done. She never felt emotional about it but just
got severe diarrhea and was confined to her room
for 3 weeks.]
OCTOR: How did you feel toward your fiancé when
he dumped you that way?
ATIENT: I was just so sick and depressed. I didn’t
feel any anger. [Patient burps again this time rubs
abdomen due to some discomfort.]
OCTOR: Did you get the stomach upset just now
ATIENT: My stomach is upset again. Just the noise
and acid again.
OCTOR: So again, when we focus on the feelings,
the cramps and acid come back.
ATIENT: For sure. What can we do about that?
OCTOR: Can we try to help you identify these feel-
ings before they go to your stomach, to try to inter-
rupt that process. Can you tell me about another
incident like that?
The patient required 3 one-hour sessions to
improve her tolerance of anxiety, so she could intel-
lectualize about feelings rather than have them
directly affect her stomach. The feelings of rejec-
tion had triggered rage and guilt about rage associ-
ated with sexual abuse by her brother and the
abandonment she felt from her mother when she
told her mother about it. With 12 sessions of ther-
apy, she was able to stop her IBS medication, anx-
iolytic, and antidepressant.
This vignette is typical for patients with
primarily smooth muscle unconscious anxiety.
The patient had no visible anxiety but had GI
symptoms when focusing on emotions about
recent trauma. The symptoms were mobilized
and reduced repeatedly, confirming a link with
emotions. Note that outwardly she looked calm,
but the emotions mobilized were being shunted
to her GI tract.
238 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
To perform these interview procedures, the physi-
cian must understand emotion physiology and
the patterns of somatization as outlined above.
This is entirely intuitive to many physicians the
first time seeing this material: they can readily
employ that which they already know. In general,
though, physicians reading this will want to pon-
der it and see how it may apply case by case as
they develop skills with it over time. Senior clini-
cians have usually done these assessments by
default, by pressure from patients, or because
they learned elements of this over time from var-
ious experiences.
Helpful short-cuts
Family physicians trained in emotion assessment
note that abbreviated elements can easily be
incorporated into a patient-centered assessment
process. For example, one may ask how “stress,”
“emotions,” or “anger” affects the person and
their body or ask how the person handles anger in
specific incidents.
In an initial patient questionnaire, one can
include a few questions that encourage the
patient to think about how stress affects them and
to describe their body’s tendency to experience
anxiety. When they later present with symptoms,
one can use these baseline data to aid in the new
assessment. Thus, a culture of considering emo-
tional factors can be woven into practice, weak-
ening any resistance to the idea that emotions and
health, mind and body, are tightly bound.
Time factors
Based on our experience, family physicians can
perform two thirds of these diagnostic assess-
ments during 15 minutes of focused interviewing.
More complex cases, such as patients with cogni-
tive disruption or multiple manifestations of anxi-
ety, may take longer to diagnose and generally
need more specialized care or referral. If required,
a patient could be asked back for a 1 half-hour
session later in the day or week.
Taking care of ourselves
Despite the importance of the emotional system in
medicine, medical curricula generally fail to pro-
vide sufficient education in this area. At the same
time, up to half of our own ranks report emotion-
al burnout.
Even with the lack of mainstream
medical teaching about emotions and health, it
behooves us to learn what we can about the emo-
tional system as it applies to the patient and to
ourselves in relation to these most challenging
problems. Focused seminars, peer case review,
select reading, and videotape training can all help
in this educational process.
The author wishes to thank the many colleagues who
reviewed and commented on this manuscript. This work is
supported by Dalhousie University, Capital Health and the
Nova Scotia Department of Health.
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... Sasuke dismisses his own need to relate to others, instead arrogantly assuming that there is no value to be gained from felt experiences. In CMT (Hobson, 1985;Meares, 2004a), dismissal, suppression, and denial of our feelings often causes our feeling states to be expressed in other ways, such as somatic symptoms, self-harm, or dissociation (Abbass, 2005;Haliburn, 2011Haliburn, , 2017. These symptoms typically worsen as the feeling states are increasingly suppressed/denied, essentially screaming for acknowledgment (Barsky, Goodson, Lane, & Cleary, 1988). ...
Graphic medicine holds promise for overcoming a client’s initial dismissal of psychotherapeutic treatment by improving their agency in their own treatment. Graphic medicine refers to the use of comics or graphic novels to facilitate the mutual understanding of psychotherapeutic processes, and may be potentially used to stimulate enjoyable discussion of a range of different experiences that may traditionally be difficult to discuss due to clients’ shame, vulnerability, fear of retraumatization, and/or the stigma of mental illness. I outline how the Japanese comic (i.e., manga) and animated film (i.e., anime) series Naruto can be used as graphic medicine for conversational model therapy (CMT), stimulating conversations without triggering the distress underlying a client’s coping mechanisms. Various concepts of CMT will be discussed within the conceptual, linguistical, and metaphorical framework already supplied by Naruto. These therapeutic conversations can potentially amplify the client’s feelings of positive affect for the manga/anime, while still relating with the similarities between their own difficulties and the negative affect portrayed by the characters.
... For instance, empirical studies have proven that emotional intelligence (Gross & John, 2002) and self-efficacy (Schwarzer, Boehmer, Luszczynska, Mohamed, & Knoll, 2005) are strong predictors of emotion regulation and coping behaviour levels, as well as persistence in overcoming difficult problems. Difficulties in emotion regulation, or poor emotion management, are linked to psychiatric disorders (Derryberry & Reed, 2003) and result in physiological reactions, including hypertension, fatigue, pain, poor diet, and sleep disturbances (Abbass, 2005). Although, coping with or managing one's emotions is necessary while engaging in the teaching practice, experienced teachers often find it difficult to manage their emotions; the situation is more complex for student teachers since they lack experience and preparation. ...
p>This study investigates the emotional responses of EFL student teachers to various affective situations during practicum and their coping strategies to enhance positive emotions and reduce negative emotions. Seventy female EFL student teachers participated in this study. To collect quantitative and qualitative data, two instruments were used: an emotional reflective diary and semi-structured interviews. The results of the study revealed that the practicum is an emotionally positive experience. The frequency of occurrence of pleasant affective situations was more than that of unpleasant ones. In the decreasing order of frequency, the most frequent emotional responses were happy, angry, and stressed and the least frequent ones were lost, influential, and shamed. Furthermore, the results indicated that student teachers adopted many regulation strategies to manage their emotions. The study recommends that teacher education programmes increase the focus on teachers’ emotions and training student teachers to manage their emotions to build future professional identities.</p
... ISTDP uses dynamic assessment to identify patients where maladaptive emotional processing may be linked to their symptoms [57]. It proposes that in these cases bodily symptoms emerge from the patient's habitual avoidance of their unconscious emotional experience and the accompanying pathophysiological anxiety states in the patient's brain and nervous system [36,42,58]. ...
The purpose of this article was to raise awareness of an under-recognized but well-supported treatment for Functional Neurological Disorders (FND) termed Intensive Short-term Dynamic Psychotherapy (ISTDP). There has been significant interest in the role of psychological mechanisms in FND onset and maintenance with specific evidence for maladaptive emotional processing. We outline how this supports the theoretical basis for ISTDP as an option in FND treatment and undertake a literature review of the current evidence base. We describe the application of ISTDP to FND illustrated through direct therapy transcripts. We conclude with reflections on the strengths and limitations of ISTDP as well as recommendations regarding future research.
... The immediate nature of the ED clinician's invitation may explain the high follow-through we observed. Consistent with our findings, a direct and seamless approach to somatization intervention is supported by existing clinical recommendation and work done in primary care settings (Abbass, 2005;Abbass et al., 2009;Cozzi et al., 2021). Our findings support the potential for cross-disciplinary collaboration between emergency and consultation psychiatry teams, in somatization identification and psychoeducation. ...
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Objective: To evaluate clinical utility and feasibility of universal somatization screening in the pediatric emergency department (ED) using a standardized approach of (1) identifying potential somatizing symptoms within the ED, (2) introducing these patients and their caregivers to the concept of the ‘mind-body connection’, (3) corroborating the likelihood of a somatization diagnosis via brief psychiatric assessment, and (4) inviting families to a psychoeducational follow-up session. Methods: We conducted a cross-sectional study to carry out this approach with families visiting a pediatric ED. Our primary outcome of screening utility was measured as the proportion of youth who screened positive for somatization by the ED clinician. Our secondary outcome of screening feasibility was measured as the proportion of patients with positives who (1) agreed to meet with the study psychiatrist, (2) consented to an ED psychiatric assessment, (3) were assessed by the study psychiatrist as likely experiencing somatization, and (4) were invited for follow-up and attended. Results: Of the 344 screened patients, 27 (7.8%) screened positive for somatization. Of these, 25 (92.6%) families verbally consented to meet the study psychiatrist to learn about the mind-body connection, and 21 (77.8%) consented to further psychiatric assessment. Upon assessment, the somatization likelihood was supported for all 21 youth. Twenty families were invited to follow-up and ultimately two (10%) attended. Conclusions: Somatization can be detected through ED-based universal screening. Few families attended psychoeducational follow-up. Further research is needed to determine appropriate ED-initiated pediatric somatization intervention.
... The presence of somatic symptoms is associated with difficulty experiencing, describing, and identifying emotions and a tendency to withdraw into fantasy (i.e., alexithymia; Bailey and Henry, 2007). Somatization thus blocks the experience of the original emotions, which may lead to greater distress (Katon et al., 2001;Abbass, 2005;Busch, 2014). Although there is overlap between somatic symptoms, anxiety, and depression (Löwe et al., 2008;Simms et al., 2012;Fu et al., 2019), somatization is a distinct phenomenon. ...
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Scientific understanding about the psychological impact of the COVID-19 global pandemic is in its nascent stage. Prior research suggests that demographic factors, such as gender and age, are associated with greater distress during a global health crisis. Less is known about how emotion regulation impacts levels of distress during a pandemic. The present study aimed to identify predictors of psychological distress during the COVID-19 pandemic. Participants (N = 2,787) provided demographics, history of adverse childhood experiences, current coping strategies (use of implicit and explicit emotion regulation), and current psychological distress. The overall prevalence of clinical levels of anxiety, depression, and post-traumatic stress was higher than the prevalence outside a pandemic and was higher than rates reported among healthcare workers and survivors of severe acute respiratory syndrome. Younger participants (<45 years), women, and non-binary individuals reported higher prevalence of symptoms across all measures of distress. A random forest machine learning algorithm was used to identify the strongest predictors of distress. Regression trees were developed to identify individuals at greater risk for anxiety, depression, and post-traumatic stress. Somatization and less reliance on adaptive defense mechanisms were associated with greater distress. These findings highlight the importance of assessing individuals’ physical experiences of psychological distress and emotion regulation strategies to help mental health providers tailor assessments and treatment during a global health crisis. © Copyright © 2020 Prout, Zilcha-Mano, Aafjes-van Doorn, Békés, Christman-Cohen, Whistler, Kui and Di Giuseppe.
... Sasuke dismisses his own need to relate to others, instead arrogantly assuming that there is no value to be gained from felt experiences. In CMT (Hobson, 1985;Meares, 2004a), dismissal, suppression, and denial of our feelings often causes our feeling states to be expressed in other ways, such as somatic symptoms, self-harm, or dissociation (Abbass, 2005;Haliburn, 2011Haliburn, , 2017. These symptoms typically worsen as the feeling states are increasingly suppressed/denied, essentially screaming for acknowledgment (Barsky, Goodson, Lane, & Cleary, 1988). ...
Full-text available
Graphic medicine holds promise for overcoming a client’s initial dismissal of psychotherapeutic treatment by improving their agency in their own treatment. Graphic medicine refers to the use of comics or graphic novels to facilitate the mutual understanding of psychotherapeutic processes, and may be potentially used to stimulate enjoyable discussion of a range of different experiences that may traditionally be difficult to discuss due to clients’ shame, vulnerability, fear of retraumatization, and/or the stigma of mental illness. I outline how the Japanese comic (i.e., manga) and animated film (i.e., anime) series Naruto can be used as graphic medicine for conversational model therapy (CMT), stimulating conversations without triggering the distress underlying a client’s coping mechanisms. Various concepts of CMT will be discussed within the conceptual, linguistical, and metaphorical framework already supplied by Naruto. These therapeutic conversations can potentially amplify the client’s feelings of positive affect for the manga/anime, while still relating with the similarities between their own difficulties and the negative affect portrayed by the characters.
The article documents a multicase study of the researcher’s own clinical work with four clients who each presented with embodied expressions of distress. The researcher practised within a ‘narrative‐dialogical’ framework and set out to build theories of therapeutic change. However, a parallel thesis emerged during the project: an autoethnographic account in which the researcher’s uses of supervision, personal therapy, dreams and life events capture data on the ways in which the therapist’s theories of change are modelled in the therapeutic space—with varying degrees of confidence and success. Sessions were audio‐recorded and coded for qualitative markers indicating the emergence of novel self‐narratives. A reflexive narrative running throughout the work highlights the superordinate role of reflexivity in theory development. Therapeutic change was typified by an evolving internalised map of self and world, with corresponding change in embodied experience. The article highlights techniques deployed by the therapist in highlighting and building upon moments of innovation with the therapeutic process. As an analysis of one therapist’s practice and the experiences of their clients, the study generates theories for ongoing exploration and study. The continuous evolution of change concepts reflects the theory‐building work of clinicians in their everyday practice. The study highlights the use of self as research instrument and offers a candid and intimate example of how practitioner research might be structured and delivered.
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Urethral syndrome (urinary symptoms and pain without organic lesions) is a frequent female pathology but its aetiology is obscure and its treatment undetermined. A number of studies have highlighted emotional disturbances in these patients. To assess the efficacy of psychotherapy in the treatment of this syndrome, the authors studied 36 patients diagnosed with urethral syndrome. Of these, 13 were randomly selected for short-term dynamic psychotherapy. The remaining 23 patients were treated with traditional urological therapies and used as the control group. After the medical diagnosis and during follow-up at 6 months and 4 years, one psychological questionnaire (SQ) was administered together with a specially prepared clinical questionnaire. The urinary symptomatology and pain disappeared completely in over 70 per cent of the patients who had completed the psychotherapy. For the remaining patients, at the termination of the treatment the symptomatology had improved to the point that it was no longer a problem. These results proved stable in time and were associated with a general improvement in psychic status, particularly for the depression, anxiety and hostility levels. In the controls, on the other hand, no significant improvement was noted in the parameters examined.
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Short-term dynamic psychotherapy is a group of well-researched brief treatments with over 50 published controlled trials testing its effectiveness against a range of treatment and nontreatment controls. Studied samples are often high users of medical services, hospital services, mental health services and disability insurance. If short-term dynamic psychotherapy is effective, it should translate into demonstrable reductions in medical and social system costs. This review examines whether or not short-term dynamic psychotherapy is a cost-effective treatment.
A substantial literature on the "hypertensive personality" links essential hypertension (EH) with the suppression of negative emotions, implying that suppression may elevate blood pressure. Yet affective inhibition might also impair communication with health care providers and exacerbate EH by limiting therapeutic collaboration. We studied 542 patient-physician interviews from a national sample to see if patients with EH (n = 203) were less likely to exhibit negative emotions than normotensive patients (n = 339) as rated by their physicians and independent observers. EH patients did not differ from others on self-rated emotional or physical health. However, physicians were less accurate in characterizing the emotional states of EH patients than those of normotensive patients, and they rated EH patients as exhibiting fewer signs of distress during the visit. Independent observers also judged the EH patients as less distressed than normotensives, thereby validating the physicians' appraisals. Content analysis disclosed that physicians paid less attention to psychosocial concerns and concentrated on biomedical matters to a greater degree with hypertensive patients than with their normotensive patients. EH patients, particularly those experiencing emotional distress, appear to have patterns of self-presentation that could present an obstacle to effective communication with their physicians, and this difficulty may be amplified by physicians' disinclination to probe for emotional difficulty.
Somatization is the experience of physical symptoms in response to emotional distress. It is common, costly, and frustrating to both the patient and physician. Successful treatment of somatization requires the physician to pursue a positive diagnosis rather than rely on a diagnosis of exclusion. Treatment consists of giving an acceptable explanation of the symptoms to the patient, avoiding unwarranted interventions, and arranging brief but regular office visits for which the patient does not need to develop a new symptom to receive medical attention.
Individuals with tension-type headache report significant anger, depression, anxiety, and stressors. However, it is not clear to what extent these variables are interrelated. The objective of the present study was to explore the role of anger in headaches, and to examine its relationship to anxiety, depression, and daily life stressors. Participants were 65 young adult women who suffered from recurrent headaches. The sample was obtained in a large-scale screening of young adult women using the Headache Symptoms List to identify those with recurrent headache. Those individuals reporting headaches completed a battery of assessment measures that included the State-Trait Anger Expression Inventory, the Mood and Anxiety Symptoms Questionnaire, and the Hassles Scale. Results revealed a significant relationship between anger suppression and depression (r = 0.40, P<.01), as well as anger expression and anxiety (r = 0.41, P<.01) for those with headache. The use of the Mood and Anxiety Symptoms Questionnaire allowed for the separate analysis of general distress symptoms and symptoms more specific to anxiety and depression. Results indicated that those with headache experience more general, nonspecific distress rather than symptoms indicative of anxiety and depression (P<.01). In addition, the mixed headache group scored high on both general (mean, 28.96) and specific measures of depression (mean, 65.76) and on anger suppression (mean, 20.12), suggesting that they might experience more psychological distress than those with tension-type headache. The present results indicate the need to distinguish the unique dimensions of anxiety and depression that should be assessed in the population with recurrent headache.
Twenty-six studies of the effectiveness of short-term dynamic therapy (STDT) were subjected to two meta-analyses. Effect sizes (ES) obtained by each method were similar. STDT attained average ESs of 71 and 34, relative to waitlist and minimal treatment groups, respectively. When studies using psychosomatic patients were excluded, STDT achieved an ES of 85, relative to waitlist groups. We found no evidence that STDT is superior or inferior to other forms of psychotherapy at posttreatment, although it evidenced a slight superiority at long-term followup assessment. There was, in addition, evidence that studies employing manuals or therapists trained in STDT produced larger ESs than those that did not.