If a patient is anxious in the office, it will be most meaningful to examine the feelings they experience during the interview.
TABLE 2
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 anxiety or defenses | The tension you had was anxiety, but how did the anger feel? |
| Becoming quiet was what you did but how did you feel inside? | |
| Observe physical responses | Observe the physical and behavioral responses in the patient 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 referra |
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 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 problem is not related to emotions are managed differently. These patients usually are quite tense and already emotionally activated. An open examination 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 findings and may include another interview, further medical investigations, referral for treatment, or follow-up to gauge the patient’s response to the interview itself.
Interpreting the patient’s responses
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 linkage to emotions. Disappearance of the symptoms by bringing emotional experiences to awareness is the best direct evidence that somatization of these emotions was causing the patient’s symptoms.
No change in a patient’s symptoms or signs—provided there was adequate emotional activation—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 symptoms with this test: she was found to have neuropathy due to multiple sclerosis. We have found that 5% to 10% of patients referred to our diagnostic clinic have physical problems that were mistaken for somatization.
TABLE 3
Interpretation of responses to emotionally focused assessment
| Response | Interpretation and action | Beware of |
|---|---|---|
| Response 1: Symptoms go up with emotional focus then down after focusing away from emotions | The diagnosis is likely somatization. Prescribe emotion-focused psychotherapy and monitor for gradual symptom removal | False positives due to coincidental symptom changes in interview |
| Health problems unrelated to the somatization could always be present | ||
| Response 2: Symptoms are improved or removed by emotional focus or emotional experience in the office | The diagnosis is (was) somatization of those emotions. Follow-up to see if gains are maintained | |
| Response 3: No change in symptoms | Somatization is unlikely to be the cause of the symptoms. Look for physical causes. | False negatives due to high defenses, sedation, lack of cooperation, inadequate focus by physician |
| Response 4: Unclear response | May or may not be an emotionbased component in the symptoms. Repeat test, consider other diagnostic tests or referral for emotion-focused diagnostic testing |
False negatives
False negatives occur when the test does not detect the process of somatization when it is present. This will occur if the level of emotion mobilized was too low, if the patient is too sedated, if the defenses the patient used were not sufficiently 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 interpretable response.