Cognitive perceptual disruption due to unconscious anxiety typically involves visual blurring, tunnel vision, loss of train of thought, and “drifting,” 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.
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 distributed 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 conversion, the striated muscles are relatively relaxed.
This finding of apparent calm while somatizing has been noted elsewhere in research of patients with hypertension. This is the “belle indifference” a patient expresses as they are temporarily relieved of muscle tension through somatization elsewhere.19
TABLE 1
Examples of diagnosable somatization patterns
| Somatization format | Observations during emotion-focused diagnostic assessment | Examples of related health complaints or health problems |
|---|---|---|
| Striated muscle tension | Progression from hand clenching, arm tension, neck tension, sighing respirations to whole-body tension | Fibromyalgia, headache, muscle spasm, backache, chest pain, shortness of breath, abdominal (wall) pain, fatigue |
| Smooth muscle tension | Relative absence of striated muscle tension. Instead activation of smooth muscles causes, for example, cramps in the abdomen or heartburn. | Irritable bowel symptoms, abdominal pain, nausea, bladder spasm, bronchospasm, coronary artery spasm, hypertension, migraine |
| Cognitive-perceptual disruption | Relative absence of striated muscle tension. Instead patient loses track of thoughts, becomes confused, gets blurry vision | Visual blurring, blindness, mental confusion, memory loss, dizziness, weakness, pseudo-seizures, paresthesias, fainting, conversion |
| Conversion | Relative absence of striated muscle tension. Instead patient goes weak in some or all voluntary muscle | Falling, aphonia, paralysis, weakness |
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.20
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 helping a patient feel emotions being stirred by recent events or from past events. Through this process one may diagnose somatization and also produce a therapeutic effect for a patient.
Direct diagnosis of somatization
An objective assessment
Because the process of somatization is unconscious to the patient, diagnosis is based on objective 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 examination of the emotional system. Although clues in the history may suggest a patient is somatizing,20 the definitive test, like that of an abdominal examination, 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.