**Rethinking Dissociation in an Age of Virtual Worlds**

Gregory Patrick Garvey

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54307

### **1. Introduction**

My previous research sought to address the general question of whether the use of virtual worlds and video games may induce experiences that fit the language used to describe dis‐ sociative disorders. The method of investigation was the development of a survey instru‐ ment based on the Structured Clinical Interview for Depersonalization – Derealization Spectrum (Mula et al., 2008). The new survey was in turn administered to a population of users of the virtual world *Second Life*. While results from this initial study provided some provisional insights the question that motivated this research remains worthy of further at‐ tention. In fact this question was originally arose from a consideration of a more general question: how do we distinguish what it real from what is virtual? From this initial question it is possible to tease out a number of questions deserving of further investigation.

A significant number of people spend a significant amount of time using virtual worlds for gaming and entertainment. According to the market research company KZERO WORLD‐ WIDE (http://www.kzero.co.uk/) the cumulative total of registered accounts for virtual worlds, MMOs (massive multi-player online games) and social gaming stands at 1.92 billion. The Entertainment Software Association (http://www.theesa.com/facts/index.asp) reports that 72 percent of American households play computer or video games. According to the Pew Research Center 97 percent of teens in the United States play videogames of some sort. (Pew Research Center 2008).

Edward Castronova argues that virtual worlds and games attract our attention because they offer more positive experiences than the real world. This places the real and the vir‐ tual in competition for people's time and attention. Castronova invokes simple economic theory to claim, that "the real world is going to lose." (Castronova 2008). With Castrono‐ va's exodus people are "moving their attention, not their bodies, and they are moving back and forth all the time."

© 2013 Garvey; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

If Castronova is right and the data on the growing numbers of users of games and virtual worlds appear to support his speculations, then we need to understand how is it that people "are moving back and forth all the time" but manage not to confuse the real and the virtual. We need to understand why and how "reality testing is intact" as people migrate back and forth from the real to the virtual.

A determined materialist might argue that this is simply a pseudo question and concern. We know the physics and electrical engineering of how the bits and bytes are represented as electrical impulses and stored on a hard drive. The engineering is well established for how the data is read, parsed into instructions and the algorithms are executed, while user input is processed resulting in the real time display of 3D computer graphics along with the play‐ back of stereo sound. We know a great about the systems of visual and auditory processing, from the anatomy of the eye and ear to the neural correlates in the brain. The reductionist can confidently say that we objectively know what is out there, is real. We thoroughly un‐ derstand the science and engineering how the virtual worlds are generated. The light from a pattern of pixels that hits the retina is just as "real" as light coming from the "real" or natu‐ ral world. We even understand a great deal about perception, both how the brain creates the

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159

But that is not the point. This reductionist argument is like trying to explain the experience of reading a novel by describing the technology of papermaking, publishing and printing. The real question centers on that human capacity to imagine fictitious worlds when hearing

What is happening when we experience the "suspension of disbelief"? What is this capacity to simultaneously know that the experience (reading fiction, watching a play or movie) is not real but still responding as if it were real? When dreaming one's motor control is sup‐ pressed. When we read a book, watch a play or film we remain seated. When we play a vid‐ eo game we interact within the constraints defined by the interface. Historically game interaction has been accomplished by use of a mouse and keyboard, or with the buttons on a game controller. More recently motion tracking and motion sensing technologies motion used with the Wii or Microsoft Kinect make it possible to interact using one's whole body.

There is also the temptation to dismiss this as a topic best suited for an introductory class in philosophy. After all the question of what is the reality of the virtual is an epis‐ temological one. Yet this does not mean that such questions have to be abandoned and left to metaphysics. Testing a series of questions and gathering data using quantitative and qualitative methods can provide meaningful results. To return to the question sug‐ gested at the onset of this chapter, does the language used to describe the diagnostic cri‐ teria for dissociative disorders specifically from the *Diagnostic and Statistical Manual of Mental Disorders*: Fourth Edition, Text Revision (2000), apply to experience of using virtu‐

In the DSM–IV–TR dissociative disorders are described as the "disruption in the usually in‐ tegrated functions of consciousness, memory, identity, or perception of the environment" and "partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements." Why is it that frequent migrations between the real and virtual do not trigger a "disruption in the usually integrated functions…"? If a subject presents symptoms of dissociation in real life do these symptoms carry over or are aggravated by use of a virtual world like *Second Life*

world out there from sensory inputs to even how the brain processes illusions.

or reading stories or watching a play or film or play a game.

al worlds or playing games?

(http://secondlife.com/)?

The use of virtual worlds is no longer an activity at the margins of society. It is now a part of the cultural fabric. Yet we have a poor understanding of the impact of this activity on the psychological well being of players. More to the point we do not understand how human beings sort out the differences between virtual experiences and real life experiences. How is it that most people easily recognize and separate these two domains of experience?

In the near future this ability will be challenged. Rapid advances in wearable computing (compact computational and sensing devices molded to comfortably fit the human body) have introduced new viewing devices that promise to further blur the lines between the real and the virtual. Announced in April 2012 Goggle's Project Glass introduces augmented real‐ ity eyewear that offers anywhere, anytime connectivity (Hill 2012). The display visible with the eyewear merges together a view of the real world with the overlay of the capabilities of web browsers and smartphones.

The *Rift Project* developed by Oculus will introduce Virtual Reality goggles in early 2013 that feature an extremely high resolution display with head motion tracking for the home market for games. As video gaming experiences become increasingly realistic, engaging and immersive how will users/players distinguish real experiences from virtual experiences? What of their long-term memories of these experiences? Will those memories of virtual ex‐ periences intermingle with memories of "real" experiences? What of dreams? Anecdotal ac‐ counts suggest that players do have dreams about gaming experiences.

With augmented reality the distinction between the real and the virtual collapses and be‐ comes a single unified experience. A person viewing the Grand Canyon through augmented reality glasses might a see text overlay identifying prominent features of that landscape. It seems quite unlikely that someone might confuse this text overlay as part of the observed reality as they can simply take off the glasses and view the natural world as it is. But what if that overlay includes a video conferencing feature similar to Skype? The individual sees a Park Ranger (who is not physically there) and hears the voice of the Ranger through their ear buds (headphones built into the glasses). The Park Ranger responds to questions, ges‐ tures to geological features in the environment (much like the weather man or woman against a green screen), engages in conversation and can even make eye contact.

For all intents and purposes this experience is real, feels real to the viewer and will be re‐ membered just as vividly (perhaps even more so?) as the experience of talking to a person standing next to him or her on the South Rim. What is substantively different about this ex‐ perience is that it is a broadband, information rich, real time interaction. This experience completely engages the participant in the visual, auditory domains and more importantly in the realm of human social affairs.

A determined materialist might argue that this is simply a pseudo question and concern. We know the physics and electrical engineering of how the bits and bytes are represented as electrical impulses and stored on a hard drive. The engineering is well established for how the data is read, parsed into instructions and the algorithms are executed, while user input is processed resulting in the real time display of 3D computer graphics along with the play‐ back of stereo sound. We know a great about the systems of visual and auditory processing, from the anatomy of the eye and ear to the neural correlates in the brain. The reductionist can confidently say that we objectively know what is out there, is real. We thoroughly un‐ derstand the science and engineering how the virtual worlds are generated. The light from a pattern of pixels that hits the retina is just as "real" as light coming from the "real" or natu‐ ral world. We even understand a great deal about perception, both how the brain creates the world out there from sensory inputs to even how the brain processes illusions.

If Castronova is right and the data on the growing numbers of users of games and virtual worlds appear to support his speculations, then we need to understand how is it that people "are moving back and forth all the time" but manage not to confuse the real and the virtual. We need to understand why and how "reality testing is intact" as people migrate back and

The use of virtual worlds is no longer an activity at the margins of society. It is now a part of the cultural fabric. Yet we have a poor understanding of the impact of this activity on the psychological well being of players. More to the point we do not understand how human beings sort out the differences between virtual experiences and real life experiences. How is

In the near future this ability will be challenged. Rapid advances in wearable computing (compact computational and sensing devices molded to comfortably fit the human body) have introduced new viewing devices that promise to further blur the lines between the real and the virtual. Announced in April 2012 Goggle's Project Glass introduces augmented real‐ ity eyewear that offers anywhere, anytime connectivity (Hill 2012). The display visible with the eyewear merges together a view of the real world with the overlay of the capabilities of

The *Rift Project* developed by Oculus will introduce Virtual Reality goggles in early 2013 that feature an extremely high resolution display with head motion tracking for the home market for games. As video gaming experiences become increasingly realistic, engaging and immersive how will users/players distinguish real experiences from virtual experiences? What of their long-term memories of these experiences? Will those memories of virtual ex‐ periences intermingle with memories of "real" experiences? What of dreams? Anecdotal ac‐

With augmented reality the distinction between the real and the virtual collapses and be‐ comes a single unified experience. A person viewing the Grand Canyon through augmented reality glasses might a see text overlay identifying prominent features of that landscape. It seems quite unlikely that someone might confuse this text overlay as part of the observed reality as they can simply take off the glasses and view the natural world as it is. But what if that overlay includes a video conferencing feature similar to Skype? The individual sees a Park Ranger (who is not physically there) and hears the voice of the Ranger through their ear buds (headphones built into the glasses). The Park Ranger responds to questions, ges‐ tures to geological features in the environment (much like the weather man or woman

For all intents and purposes this experience is real, feels real to the viewer and will be re‐ membered just as vividly (perhaps even more so?) as the experience of talking to a person standing next to him or her on the South Rim. What is substantively different about this ex‐ perience is that it is a broadband, information rich, real time interaction. This experience completely engages the participant in the visual, auditory domains and more importantly in

counts suggest that players do have dreams about gaming experiences.

against a green screen), engages in conversation and can even make eye contact.

it that most people easily recognize and separate these two domains of experience?

forth from the real to the virtual.

158 Mental Disorders - Theoretical and Empirical Perspectives

web browsers and smartphones.

the realm of human social affairs.

But that is not the point. This reductionist argument is like trying to explain the experience of reading a novel by describing the technology of papermaking, publishing and printing. The real question centers on that human capacity to imagine fictitious worlds when hearing or reading stories or watching a play or film or play a game.

What is happening when we experience the "suspension of disbelief"? What is this capacity to simultaneously know that the experience (reading fiction, watching a play or movie) is not real but still responding as if it were real? When dreaming one's motor control is sup‐ pressed. When we read a book, watch a play or film we remain seated. When we play a vid‐ eo game we interact within the constraints defined by the interface. Historically game interaction has been accomplished by use of a mouse and keyboard, or with the buttons on a game controller. More recently motion tracking and motion sensing technologies motion used with the Wii or Microsoft Kinect make it possible to interact using one's whole body.

There is also the temptation to dismiss this as a topic best suited for an introductory class in philosophy. After all the question of what is the reality of the virtual is an epis‐ temological one. Yet this does not mean that such questions have to be abandoned and left to metaphysics. Testing a series of questions and gathering data using quantitative and qualitative methods can provide meaningful results. To return to the question sug‐ gested at the onset of this chapter, does the language used to describe the diagnostic cri‐ teria for dissociative disorders specifically from the *Diagnostic and Statistical Manual of Mental Disorders*: Fourth Edition, Text Revision (2000), apply to experience of using virtu‐ al worlds or playing games?

In the DSM–IV–TR dissociative disorders are described as the "disruption in the usually in‐ tegrated functions of consciousness, memory, identity, or perception of the environment" and "partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements." Why is it that frequent migrations between the real and virtual do not trigger a "disruption in the usually integrated functions…"? If a subject presents symptoms of dissociation in real life do these symptoms carry over or are aggravated by use of a virtual world like *Second Life* (http://secondlife.com/)?

The DSM-IV-TR acknowledges that dissociative states "occur frequently and are not inher‐ ently pathological" and are even "sought-after experiences as part of long standing religious and cultural rituals and practices." Many conditions present similar clusters of symptoms, yet the language used in the DSM for the diagnostic criteria for depersonalization and derealization is a fitting description for how avatars (the user's onscreen representation in a virtual world or game) look "unreal" and one's surroundings looks "unreal" in a virtual worlds like the *SIMS*, *The World of Warcraft* or *Second Life*. These virtual worlds are all com‐ puter generated 3D computer graphics simulations that in spite of considerable advances in real time rendering fall well short of photo-realism and still look fake and cartoonish.

agnostic criteria then there may be something worth further scrutiny. In order to conduct a more systematic investigation the development of a survey instrument and its deployment

Rethinking Dissociation in an Age of Virtual Worlds

http://dx.doi.org/10.5772/54307

161

The Structured Clinical Interview for Depersonalization – Derealization Spectrum (SCI-DER) (Mula et al., 2008) was chosen as a model for a new survey. Questions were selected on the basis of how well they applied to the experience of using *Second Life.* Those questions that referenced situations that could only be experienced in "real life" were not used. Some questions were used as is or were minimally rewritten to clearly reference the experience of using *Second Life.* This newly created survey instrument was administered to a select popu‐ lation of users of *Second Life*. A parsimonious interpretation of the initial results, suggest that a significant number of survey respondents agreed that the descriptions of dissociative ex‐ periences based on the diagnostic criteria of the DSM-IV-TR do apply to the experience of

The SCI-DER introduces the survey questions with this general question: "Have you ever experienced just for a few seconds or for days or months. …" After that each of the specific

This preface from the SCI\_DER is rewritten for the new survey as: "While in Second Life have you ever experienced just for a few seconds or for a longer period of time…" The first question

Questions were added that addressed gender, age and length of time spent as a registered user (resident) of Second Life. In the end the new survey instrument comprised a total of 23 questions. Respondents answered Yes or No to each. While the SCI-DER is considered a va‐ lidated instrument with high reliability, this new survey does not make any such claims. Additionally this new survey was not intended to be used for the purposes of diagnosis. The survey was administered by the Social Research Foundation (http://www.socialresearch‐ foundation.org/) to a sample population of 110 "residents" of Second Life. Respondents completed the survey online anonymously. The following charts show sample results of this new survey using questions modified from the SCI-DER. As noted above the list of twenty-

*While in Second Life have you ever experienced just for a few seconds or for a longer period of time…*

Question 1 uses the descriptive phrase directly from the diagnostic criteria of the DSM-IV-TR and corresponds to the first domain of questions in the SCI-DER. Items in this domain focus on derealization or "referring to an altered experience of the external world (Mula et al., 2008)." Question 2 is another example of this domain. Survey responses suggest that it is "normal" and expected to view other avatars and objects as "not real" when logged into *Second Life.* Indeed it is likely a desirable and sought after experience whereas to experience

the "real" world as "strange and unreal" is disturbing and potentially disabling.

questions follow such as the first: *… that the outside world was strange and unreal?*

…that the virtual world was strange and unreal?"

three questions is prefaced by this general question:

*…that the virtual world was strange and unreal?*

is modified as follows to refer directly to the experience of being logged into *Second Life.*

was required.

using virtual worlds.

The DSM-IV-TR uses the following criteria for derealization: "The perception or experience of the external world so that it seems strange or unreal; Feeling as though one's environment is lacking in spontaneity, emotional colouring and depth." In *Second Life* the objects, archi‐ tecture and avatars representing other residents appear "strange and unreal" and are "lack‐ ing in spontaneity, emotional coloring (especially other avatars) and depth."

The diagnostic criteria for Item 300.6 Depersonalization Disorder specifies the following: "Persistent or recurrent feelings of being detached from one's mental processes or body; as if an observer; During depersonalization, reality testing is intact." In *Second Life* users see their avatars from a default point-of-view (POV) slightly above and behind their "in world" ava‐ tar. This is not unlike descriptions of out-of-body experiences. Users can also use a viewing technique called mouse-look which makes it possible for a user to view his or her own ava‐ tar as if it were someone else. Avatars controlled by other users can "seem unfamiliar or me‐ chanical" or "robotic".

Updated in DSM-IV-TR, Dissociative Identity Disorder (DID) refers to the "presence of two or more distinct identities or personality states" that "recurrently take control" of a person's behavior. It is a common practice for *Second Life* users to have multiple "in-world" avatars (known as alts) that can be of a different gender. The user effectively takes on a different personality and behavior when employing a different avatar.

### **2. A Survey and results**

It is an informal observation to say that the language of the diagnostic criteria of the DSM is an apt description of the experience using a virtual world like *Second Life.* To say that a com‐ puter generated simulation of a world looks "strange, unreal" or that the avatars in that vir‐ tual world "seem unfamiliar or mechanical" or "robotic" is a matter-of-fact statement. Similarly asserting that for most users and players "reality testing is intact" is likewise an uncontroversial truism.

To suggest that users and players who have multiple avatars may experience something akin to dissociative identity disorder is another matter. These terms and phrases have real import when used as part of the diagnostic criteria for dissociative disorders. If users selfreport and respond in the affirmative to a self-administered questionnaire related to the di‐ agnostic criteria then there may be something worth further scrutiny. In order to conduct a more systematic investigation the development of a survey instrument and its deployment was required.

The Structured Clinical Interview for Depersonalization – Derealization Spectrum (SCI-DER) (Mula et al., 2008) was chosen as a model for a new survey. Questions were selected on the basis of how well they applied to the experience of using *Second Life.* Those questions that referenced situations that could only be experienced in "real life" were not used. Some questions were used as is or were minimally rewritten to clearly reference the experience of using *Second Life.* This newly created survey instrument was administered to a select popu‐ lation of users of *Second Life*. A parsimonious interpretation of the initial results, suggest that a significant number of survey respondents agreed that the descriptions of dissociative ex‐ periences based on the diagnostic criteria of the DSM-IV-TR do apply to the experience of using virtual worlds.

The SCI-DER introduces the survey questions with this general question: "Have you ever experienced just for a few seconds or for days or months. …" After that each of the specific questions follow such as the first: *… that the outside world was strange and unreal?*

This preface from the SCI\_DER is rewritten for the new survey as: "While in Second Life have you ever experienced just for a few seconds or for a longer period of time…" The first question is modified as follows to refer directly to the experience of being logged into *Second Life.*

…that the virtual world was strange and unreal?"

The DSM-IV-TR acknowledges that dissociative states "occur frequently and are not inher‐ ently pathological" and are even "sought-after experiences as part of long standing religious and cultural rituals and practices." Many conditions present similar clusters of symptoms, yet the language used in the DSM for the diagnostic criteria for depersonalization and derealization is a fitting description for how avatars (the user's onscreen representation in a virtual world or game) look "unreal" and one's surroundings looks "unreal" in a virtual worlds like the *SIMS*, *The World of Warcraft* or *Second Life*. These virtual worlds are all com‐ puter generated 3D computer graphics simulations that in spite of considerable advances in

real time rendering fall well short of photo-realism and still look fake and cartoonish.

ing in spontaneity, emotional coloring (especially other avatars) and depth."

personality and behavior when employing a different avatar.

chanical" or "robotic".

160 Mental Disorders - Theoretical and Empirical Perspectives

**2. A Survey and results**

uncontroversial truism.

The DSM-IV-TR uses the following criteria for derealization: "The perception or experience of the external world so that it seems strange or unreal; Feeling as though one's environment is lacking in spontaneity, emotional colouring and depth." In *Second Life* the objects, archi‐ tecture and avatars representing other residents appear "strange and unreal" and are "lack‐

The diagnostic criteria for Item 300.6 Depersonalization Disorder specifies the following: "Persistent or recurrent feelings of being detached from one's mental processes or body; as if an observer; During depersonalization, reality testing is intact." In *Second Life* users see their avatars from a default point-of-view (POV) slightly above and behind their "in world" ava‐ tar. This is not unlike descriptions of out-of-body experiences. Users can also use a viewing technique called mouse-look which makes it possible for a user to view his or her own ava‐ tar as if it were someone else. Avatars controlled by other users can "seem unfamiliar or me‐

Updated in DSM-IV-TR, Dissociative Identity Disorder (DID) refers to the "presence of two or more distinct identities or personality states" that "recurrently take control" of a person's behavior. It is a common practice for *Second Life* users to have multiple "in-world" avatars (known as alts) that can be of a different gender. The user effectively takes on a different

It is an informal observation to say that the language of the diagnostic criteria of the DSM is an apt description of the experience using a virtual world like *Second Life.* To say that a com‐ puter generated simulation of a world looks "strange, unreal" or that the avatars in that vir‐ tual world "seem unfamiliar or mechanical" or "robotic" is a matter-of-fact statement. Similarly asserting that for most users and players "reality testing is intact" is likewise an

To suggest that users and players who have multiple avatars may experience something akin to dissociative identity disorder is another matter. These terms and phrases have real import when used as part of the diagnostic criteria for dissociative disorders. If users selfreport and respond in the affirmative to a self-administered questionnaire related to the di‐ Questions were added that addressed gender, age and length of time spent as a registered user (resident) of Second Life. In the end the new survey instrument comprised a total of 23 questions. Respondents answered Yes or No to each. While the SCI-DER is considered a va‐ lidated instrument with high reliability, this new survey does not make any such claims. Additionally this new survey was not intended to be used for the purposes of diagnosis. The survey was administered by the Social Research Foundation (http://www.socialresearch‐ foundation.org/) to a sample population of 110 "residents" of Second Life. Respondents completed the survey online anonymously. The following charts show sample results of this new survey using questions modified from the SCI-DER. As noted above the list of twentythree questions is prefaced by this general question:

*While in Second Life have you ever experienced just for a few seconds or for a longer period of time…*

### *…that the virtual world was strange and unreal?*

Question 1 uses the descriptive phrase directly from the diagnostic criteria of the DSM-IV-TR and corresponds to the first domain of questions in the SCI-DER. Items in this domain focus on derealization or "referring to an altered experience of the external world (Mula et al., 2008)." Question 2 is another example of this domain. Survey responses suggest that it is "normal" and expected to view other avatars and objects as "not real" when logged into *Second Life.* Indeed it is likely a desirable and sought after experience whereas to experience the "real" world as "strange and unreal" is disturbing and potentially disabling.

*… having the feeling that other avatars, objects, and the 'in-world' environment around you were not real?*

**3. Other considerations**

is a place set apart for not only play but also much more:

as well as mentally to grasp any entity at all."

stantly back into "real life."

Digital games conjure up virtual worlds by means of graphical displays. Play further estab‐ lishes the divide between the real and the virtual by demarcating what play theorists call the magic circle. First described by Huizinga in his seminal work on play (1955) the magic circle

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*"All play moves and has its being within a play-ground marked off beforehand either materially or ideally, deliberately or as a matter of course. Just as there is no formal difference between play and ritual, so the 'consecrated spot' cannot be formally distin‐ guished from the play-ground. The arena, the card-table, the magic circle, the temple, the stage, the screen, the tennis court, the court of justice, etc., are all in form and function play-grounds, i.e. forbidden spots, isolated, hedged round, hallowed, within which*

Gregory Bateson (1972) links play to Goffman's frame analysis (1974): "play occurs within a delimited psychological frame, a spatial and temporal bounding of a set of interactive mes‐ sages." Goffman himself aims at a certain granularity of experience by using the term "strip" by which he means "any arbitrary slice or cut from the stream of ongoing activity, including here sequences of happenings, real or fictive, as seen from the perspective of those subjectively involved in sustaining an interest in them (Goffman 1974)." In a similar fashion Zerubavel (1991) speaks of "mental fences," which "delimit geographical areas, historical events, people, ideas, and so on that appear to be contiguous, similar, functionally related, or otherwise associated." Zerubavel, (1991) reminds us that boundaries allow us to "visually

Salen and Zimmerman (2003) link Huizinga's (1955) notion of the 'magic circle' to Bateson's analysis of play as a frame that "delimits the peculiar space of play." When someone engag‐ es in play, he/she crosses a boundary (into the magic circle) that separates the artificial world of the game from "real life." The magic circle is a frame that sets a thick boundary between real life and the make believe of game play. This cognitive frame establishes the "reality" of the game. Anthropologist Tom Boellstroff (2008) suggests that the "magic cir‐ cle"– may constitute a virtual world meaningful in its own right. Bateson points out that this is a paradoxical state of mind (Bateson 1972, p. 84). For the player the game is simultaneous‐ ly real and not real. This boundary is likewise thin–the player can easily stop and step in‐

Work-family-life border/boundaries theories (Ashforth 2000; Clark 2000) likewise make use of the concepts of boundaries and borders to understand how daily life is "sliced" into dis‐ crete domains. These theories study the conflicts and interactions that arise between the do‐ mains of work, family life and what is termed third places defined as social activities outside the home or work place. This partitioning makes it possible for "one to concentrate more on

whatever domain is currently salient and less on other domains."

*special rules obtain. All are temporary worlds within the ordinary world, dedicated to the performance of an act apart."*

Question 12 references the *Somatopsychic depersonalization* domain which "describes a variety of changes in body experience such as lack of body ownership feelings, feelings of disem‐ bodiment, which can range from a nonspecific feeling of not being in the body to out-ofbody experiences and autoscopic hallucinations (Mula et al., 2008)."

*… that you were not in charge of your avatar's movements, so that you felt "automatic" and mechan‐ ical as if you were a robot?*

Questions 17 and 18 reference the third domain of Auto Psychic depersonalization which includes "unfamiliarity of the self in terms of sensation of being an outside ob‐ server of one's mental process, not being 'in charge' of their own behavior or mental processes, the automaton-line experience and anomalous subjective recall." Yes respons‐ es are not surprising given that the default viewpoint in *Second Life* is from a vantage point slightly above and behind their "in-world" avatar. In fact residents often use *Mouse Look* (Second Life Wikia, n.d.) where it is possible to move the camera repre‐ senting their avatar's point-of-view, independent of the location of their avatar. This makes it possible to observe their own avatar as if they were "detached from one's body;" as if "an observer."

#### *… that you were a "detached observer"?*

Question 18 references the déjà vu experience. Sims (simulations) in Second Life have a sameness to them because of the basic technology consists of complex shapes built out of primitive shapes with simple texture maps. Question 18 also references item 300.13 Dis‐ sociative Fugue in the DSM-IV-TR where the "predominant disturbance is sudden, unex‐ pected travel away from home or one's customary place of work, with inability to recall one's past."

#### *… that when in a new situation, you had been there before?*

Question 23 references the DSM-IV-TR category 300.14 *Dissociative Identity Disorder*. Male and female responses differ by only 1.5 percentage points. These results suggest that nearly half of the population of residents use "alts" or alternative avatars that have "distinct per‐ sonalities." It is not clear from these responses if these personalities take control but most Second Life users enact or "perform" their avatar in a way consistent with its appearance. Item 300.14 Dissociative Fugue is also implicated here as it involves "Confusion about per‐ sonal identity, or the assumption of a new identity, (partial or complete)."

#### *… that you use two or more distinct avatars having different personalities?*

Some value lies in this survey's potential to define and recognize potential manifesta‐ tions that (weakly) correlate to DSM-IV diagnostic criteria. This has led to further re‐ search questions (as noted above) that suggest the development of new instruments and methodologies.

### **3. Other considerations**

*… having the feeling that other avatars, objects, and the 'in-world' environment around you were*

Question 12 references the *Somatopsychic depersonalization* domain which "describes a variety of changes in body experience such as lack of body ownership feelings, feelings of disem‐ bodiment, which can range from a nonspecific feeling of not being in the body to out-of-

*… that you were not in charge of your avatar's movements, so that you felt "automatic" and mechan‐*

Questions 17 and 18 reference the third domain of Auto Psychic depersonalization which includes "unfamiliarity of the self in terms of sensation of being an outside ob‐ server of one's mental process, not being 'in charge' of their own behavior or mental processes, the automaton-line experience and anomalous subjective recall." Yes respons‐ es are not surprising given that the default viewpoint in *Second Life* is from a vantage point slightly above and behind their "in-world" avatar. In fact residents often use *Mouse Look* (Second Life Wikia, n.d.) where it is possible to move the camera repre‐ senting their avatar's point-of-view, independent of the location of their avatar. This makes it possible to observe their own avatar as if they were "detached from one's

Question 18 references the déjà vu experience. Sims (simulations) in Second Life have a sameness to them because of the basic technology consists of complex shapes built out of primitive shapes with simple texture maps. Question 18 also references item 300.13 Dis‐ sociative Fugue in the DSM-IV-TR where the "predominant disturbance is sudden, unex‐ pected travel away from home or one's customary place of work, with inability to recall

Question 23 references the DSM-IV-TR category 300.14 *Dissociative Identity Disorder*. Male and female responses differ by only 1.5 percentage points. These results suggest that nearly half of the population of residents use "alts" or alternative avatars that have "distinct per‐ sonalities." It is not clear from these responses if these personalities take control but most Second Life users enact or "perform" their avatar in a way consistent with its appearance. Item 300.14 Dissociative Fugue is also implicated here as it involves "Confusion about per‐

Some value lies in this survey's potential to define and recognize potential manifesta‐ tions that (weakly) correlate to DSM-IV diagnostic criteria. This has led to further re‐ search questions (as noted above) that suggest the development of new instruments and

sonal identity, or the assumption of a new identity, (partial or complete)."

*… that you use two or more distinct avatars having different personalities?*

body experiences and autoscopic hallucinations (Mula et al., 2008)."

*not real?*

*ical as if you were a robot?*

162 Mental Disorders - Theoretical and Empirical Perspectives

body;" as if "an observer."

one's past."

methodologies.

*… that you were a "detached observer"?*

*… that when in a new situation, you had been there before?*

Digital games conjure up virtual worlds by means of graphical displays. Play further estab‐ lishes the divide between the real and the virtual by demarcating what play theorists call the magic circle. First described by Huizinga in his seminal work on play (1955) the magic circle is a place set apart for not only play but also much more:

*"All play moves and has its being within a play-ground marked off beforehand either materially or ideally, deliberately or as a matter of course. Just as there is no formal difference between play and ritual, so the 'consecrated spot' cannot be formally distin‐ guished from the play-ground. The arena, the card-table, the magic circle, the temple, the stage, the screen, the tennis court, the court of justice, etc., are all in form and function play-grounds, i.e. forbidden spots, isolated, hedged round, hallowed, within which special rules obtain. All are temporary worlds within the ordinary world, dedicated to the performance of an act apart."*

Gregory Bateson (1972) links play to Goffman's frame analysis (1974): "play occurs within a delimited psychological frame, a spatial and temporal bounding of a set of interactive mes‐ sages." Goffman himself aims at a certain granularity of experience by using the term "strip" by which he means "any arbitrary slice or cut from the stream of ongoing activity, including here sequences of happenings, real or fictive, as seen from the perspective of those subjectively involved in sustaining an interest in them (Goffman 1974)." In a similar fashion Zerubavel (1991) speaks of "mental fences," which "delimit geographical areas, historical events, people, ideas, and so on that appear to be contiguous, similar, functionally related, or otherwise associated." Zerubavel, (1991) reminds us that boundaries allow us to "visually as well as mentally to grasp any entity at all."

Salen and Zimmerman (2003) link Huizinga's (1955) notion of the 'magic circle' to Bateson's analysis of play as a frame that "delimits the peculiar space of play." When someone engag‐ es in play, he/she crosses a boundary (into the magic circle) that separates the artificial world of the game from "real life." The magic circle is a frame that sets a thick boundary between real life and the make believe of game play. This cognitive frame establishes the "reality" of the game. Anthropologist Tom Boellstroff (2008) suggests that the "magic cir‐ cle"– may constitute a virtual world meaningful in its own right. Bateson points out that this is a paradoxical state of mind (Bateson 1972, p. 84). For the player the game is simultaneous‐ ly real and not real. This boundary is likewise thin–the player can easily stop and step in‐ stantly back into "real life."

Work-family-life border/boundaries theories (Ashforth 2000; Clark 2000) likewise make use of the concepts of boundaries and borders to understand how daily life is "sliced" into dis‐ crete domains. These theories study the conflicts and interactions that arise between the do‐ mains of work, family life and what is termed third places defined as social activities outside the home or work place. This partitioning makes it possible for "one to concentrate more on whatever domain is currently salient and less on other domains."

These borders can be both flexible and permeable. Behavior can spill over from one do‐ main into another when flexible boundaries allow a role to "be enacted in various set‐ tings as various times (Ashforth et al. 2000)." Flexible borders or boundaries can be characterized by the "degree to which the spatial and temporal boundaries are pliable." A role having flexible boundaries "can be enacted in various settings and at various times". Permeability can be measured as "the degree to which a role allows one to be physically located in the role's domain but psychologically and/or behaviorally involved in another role (Ashforth et al. 2000)."

Perceptual boundaries Between sensory inputs Sensory focus or "bandwidth" Around perceptual entities

Between thought and feeling

Sleep-dream-wake boundaries Between sleep and waking Between dreaming and waking In and around the dream

Boundaries related to play Boundaries related to memory

Daydreaming

Early memories

Personal past Future plans

Personal space

Sexual identity

Constancy of identity Group boundaries

Barriers against stimuli The skin as a boundary

Interpersonal boundaries

Boundaries related to thoughts and feelings Between two thoughts or two feelings

Around thoughts and feelings (free association)

Recent memories and memory organization

Boundaries around oneself (body boundaries)

Boundaries between conscious and unconscious and between id, ego, and superego

Posture and musculature as boundaries

Defense mechanisms as boundaries Boundaries related to identity

Age identity: Between adult and child

Boundaries in organizing one's life Boundaries in environmental preferences Boundaries in opinion and judgments Boundaries in decision making and action

**Table 1.** Types of Boundaries (Hartmann et al. 2001)

Boundaries between states of awareness or states of consciousness

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The framework of border/boundary theory does not take into account domains beyond socalled third places. I have argued elsewhere (Garvey 2010) that the virtual should be consid‐ ered as a fourth place. The analytical tool set of work-family-life border/boundary theories does not capture the full dynamic of the phenomena of immersion in the domains of virtual worlds and video games. These theories as currently formulated have little to say about how gamers are "quite facile at juggling roles" and how gamers can easily and quickly navigate back and forth between the domains of play (the virtual) and real life.

### **4. Toward a new survey**

The foregoing discussion suggests that a number a new survey instruments could be de‐ vised that would examine the notion of the magic circle, paradoxical states of mind as mani‐ fested in game play, role-playing and boundaries. Goffman's notion of frames has enormous intuitive appeal but suffers from an awkwardness of how to design experimental questions that get at this idea, that are testable and indeed quantifiable. Boundaries and borders have likewise a certain conceptual appeal. But as discussed above the border/boundary frame‐ work suffers from certain limitations when we try to apply this framework beyond the work/family balance framework.

The Boundary Questionnaire (Hartmann, 1991; Hartmann, Harrison and Zborowski 2001) offers another approach to using the notion of boundaries as an investigative tool. The BQ is a 138-item instrument that covers 12 categories of boundaries. Hartmann et al. point out that there is a long tradition in the field of psychology of investigating "perceptual boundaries, boundaries related to thoughts and feelings, boundaries between states of awareness or con‐ sciousness, sleep-dream-wake boundaries, boundaries related to memory, body boundaries, interpersonal boundaries, boundaries related to sexual identity and other forms of identity, group boundaries, and boundaries in opinions and judgments." Hartmann et al. (1991; 2001), distinguish thick (solid) boundaries from thin or permeable boundaries. They have al‐ so developed a theory of dreams based on a "wake-dreaming continuum (Hartman 1989; Hartmann & Kunzendorf 2007)." This continuum begins on one end with "focused waking thought" having thick boundaries characterized by "solid, divisions, categorizations." On the other end of the continuum is "Dreaming" having "thin boundaries" characterized as "merging, condensation, loosening of categories." Hartmann et al. (2001) introduces the fol‐ lowing table compiling types of boundaries:

Perceptual boundaries Between sensory inputs Sensory focus or "bandwidth" Around perceptual entities Boundaries related to thoughts and feelings Between two thoughts or two feelings Between thought and feeling Around thoughts and feelings (free association) Boundaries between states of awareness or states of consciousness Sleep-dream-wake boundaries Between sleep and waking Between dreaming and waking In and around the dream Daydreaming Boundaries related to play Boundaries related to memory Early memories Recent memories and memory organization Personal past Future plans Boundaries around oneself (body boundaries) Barriers against stimuli The skin as a boundary Posture and musculature as boundaries Personal space Interpersonal boundaries Boundaries between conscious and unconscious and between id, ego, and superego Defense mechanisms as boundaries Boundaries related to identity Sexual identity Age identity: Between adult and child Constancy of identity Group boundaries Boundaries in organizing one's life Boundaries in environmental preferences Boundaries in opinion and judgments Boundaries in decision making and action

**Table 1.** Types of Boundaries (Hartmann et al. 2001)

These borders can be both flexible and permeable. Behavior can spill over from one do‐ main into another when flexible boundaries allow a role to "be enacted in various set‐ tings as various times (Ashforth et al. 2000)." Flexible borders or boundaries can be characterized by the "degree to which the spatial and temporal boundaries are pliable." A role having flexible boundaries "can be enacted in various settings and at various times". Permeability can be measured as "the degree to which a role allows one to be physically located in the role's domain but psychologically and/or behaviorally involved

The framework of border/boundary theory does not take into account domains beyond socalled third places. I have argued elsewhere (Garvey 2010) that the virtual should be consid‐ ered as a fourth place. The analytical tool set of work-family-life border/boundary theories does not capture the full dynamic of the phenomena of immersion in the domains of virtual worlds and video games. These theories as currently formulated have little to say about how gamers are "quite facile at juggling roles" and how gamers can easily and quickly navigate

The foregoing discussion suggests that a number a new survey instruments could be de‐ vised that would examine the notion of the magic circle, paradoxical states of mind as mani‐ fested in game play, role-playing and boundaries. Goffman's notion of frames has enormous intuitive appeal but suffers from an awkwardness of how to design experimental questions that get at this idea, that are testable and indeed quantifiable. Boundaries and borders have likewise a certain conceptual appeal. But as discussed above the border/boundary frame‐ work suffers from certain limitations when we try to apply this framework beyond the

The Boundary Questionnaire (Hartmann, 1991; Hartmann, Harrison and Zborowski 2001) offers another approach to using the notion of boundaries as an investigative tool. The BQ is a 138-item instrument that covers 12 categories of boundaries. Hartmann et al. point out that there is a long tradition in the field of psychology of investigating "perceptual boundaries, boundaries related to thoughts and feelings, boundaries between states of awareness or con‐ sciousness, sleep-dream-wake boundaries, boundaries related to memory, body boundaries, interpersonal boundaries, boundaries related to sexual identity and other forms of identity, group boundaries, and boundaries in opinions and judgments." Hartmann et al. (1991; 2001), distinguish thick (solid) boundaries from thin or permeable boundaries. They have al‐ so developed a theory of dreams based on a "wake-dreaming continuum (Hartman 1989; Hartmann & Kunzendorf 2007)." This continuum begins on one end with "focused waking thought" having thick boundaries characterized by "solid, divisions, categorizations." On the other end of the continuum is "Dreaming" having "thin boundaries" characterized as "merging, condensation, loosening of categories." Hartmann et al. (2001) introduces the fol‐

back and forth between the domains of play (the virtual) and real life.

in another role (Ashforth et al. 2000)."

164 Mental Disorders - Theoretical and Empirical Perspectives

**4. Toward a new survey**

work/family balance framework.

lowing table compiling types of boundaries:

The Boundary Questionnaire (BQ) organizes those various kinds of boundaries into twelve categories (Hartmann et al. 2001):

**Category 1: Sleep/Dream/Waking**

**Category 2: Unusual Experiences**

*100. I have had déjà vu experiences.*

The modified questions are:

*61. At times I have felt as if I were coming apart.*

*100. In Second Life I have had déjà vu experiences.*

*15. Sometimes I don't know whether I am thinking or feeling.*

that have animal heads, tails and paws. The modified questions are:

*40. I have definite plans for my future. I can lay out pretty well what I expect*

*4. I am very close to my childhood feelings when using Second Life.*

*53. When I get involved with someone, we sometimes get too close.*

*53. When I get involved with someone in Second Life, we sometimes get too close.*

**Category 3: Thoughts/Feelings/Moods**

**Category 4: Childhood/Adolescence/Adult** *4. I am very close to my childhood feelings.*

*year by year for the next few years.* The modified questions are:

*next few years.*

**Category 5: Interpersonal**

*103. I am a very open person.* The modified questions are:

**Category 6: Sensitivity**

*103. In Second Life I am a very open person.*

*37. I spend a lot of time daydreaming, fantasizing, or in reverie.*

*1. When I awake in the morning, I am not sure whether I am really awake for a few minutes.*

*37. I spend a lot of time daydreaming, fantasizing, or in reverie about Second Life.*

*61. At times while using Second Life I have felt as if I were coming apart.*

*74. I can easily imagine myself to be an animal or what it might be like to be an animal.*

*15. Sometimes while using Second Life I don't know whether I am thinking or feeling.*

*74. In Second Life I can easily imagine myself to be a furry or what it might be like to be a furry.*

Agreement with these questions are indicative of thin boundaries. Question 1 and 37 could be modified as follows: *1. When I awake in the morning, I am not sure for a few minutes whether I am logged into Second Life or really awake.*

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In Second Life users can change the appearance of their avatar. A large group of users choose to be furries – avatars

*40. I have definite plans for my future logins in Second Life. I can lay out pretty well what I expect year by year for the*


**Table 2.** Categories of Boundaries (Hartmann et al. 2001)

Hartmann et al. (2001) argue that "thick vs. thin boundaries appears to be a robust personal‐ ity measure, which can be considered an important dimension of personality." Boundaries related to "sexual identity" and "constancy of identity" are of direct relevance in a discus‐ sion of the use of avatars in virtual worlds and games. Thus the BQ might serve as a model for a new survey. In order to make such an instrument relevant to the target population the questions in the BQ could be slightly revised in a similar fashion to the approach described above with the SCI-DER.

The following table (Hartmann et al. 2001) lists the each of the twelve categories of boun‐ dary types. Under each category are two sample items from original the BQ followed by re‐ visions of each items modified in such a way that it applies to the experience of using the virtual world *Second Life*. Subjects are given instructions to rate each of the statements on a scale from 0 to 4, where "0" indicates either the subject thinks the statement does not apply to him/her (not at all or not at all true of me). A "4" indicates that the subject thinks the statement definitely applies (true of me).

#### **Category 1: Sleep/Dream/Waking**

The Boundary Questionnaire (BQ) organizes those various kinds of boundaries into twelve

Hartmann et al. (2001) argue that "thick vs. thin boundaries appears to be a robust personal‐ ity measure, which can be considered an important dimension of personality." Boundaries related to "sexual identity" and "constancy of identity" are of direct relevance in a discus‐ sion of the use of avatars in virtual worlds and games. Thus the BQ might serve as a model for a new survey. In order to make such an instrument relevant to the target population the questions in the BQ could be slightly revised in a similar fashion to the approach described

The following table (Hartmann et al. 2001) lists the each of the twelve categories of boun‐ dary types. Under each category are two sample items from original the BQ followed by re‐ visions of each items modified in such a way that it applies to the experience of using the virtual world *Second Life*. Subjects are given instructions to rate each of the statements on a scale from 0 to 4, where "0" indicates either the subject thinks the statement does not apply to him/her (not at all or not at all true of me). A "4" indicates that the subject thinks the

categories (Hartmann et al. 2001):

166 Mental Disorders - Theoretical and Empirical Perspectives

Category 1: Sleep/Dream/Waking

Category 2: Unusual Experiences

Category 5: Interpersonal

Category 7: Neat/Exact/Precise

Category 8: Edges/Lines/Clothing

Category 10: Organizations

Category 12: Beauty/Truth

above with the SCI-DER.

Category 9: Opinions re Children, etc.

Category 11: Peoples/Nations/Groups

**Table 2.** Categories of Boundaries (Hartmann et al. 2001)

statement definitely applies (true of me).

Category 6: Sensitivity

Category 3: Thoughts/Feelings/Moods

Category 4: Childhood/Adolescence/Adult

*1. When I awake in the morning, I am not sure whether I am really awake for a few minutes.*

*37. I spend a lot of time daydreaming, fantasizing, or in reverie.*

Agreement with these questions are indicative of thin boundaries. Question 1 and 37 could be modified as follows:

*1. When I awake in the morning, I am not sure for a few minutes whether I am logged into Second Life or really awake.*

*37. I spend a lot of time daydreaming, fantasizing, or in reverie about Second Life.*

#### **Category 2: Unusual Experiences**

*61. At times I have felt as if I were coming apart.*

*100. I have had déjà vu experiences.*

The modified questions are:

*61. At times while using Second Life I have felt as if I were coming apart.*

*100. In Second Life I have had déjà vu experiences.*

#### **Category 3: Thoughts/Feelings/Moods**

*15. Sometimes I don't know whether I am thinking or feeling.*

*74. I can easily imagine myself to be an animal or what it might be like to be an animal.*

In Second Life users can change the appearance of their avatar. A large group of users choose to be furries – avatars

that have animal heads, tails and paws. The modified questions are:

*15. Sometimes while using Second Life I don't know whether I am thinking or feeling.*

*74. In Second Life I can easily imagine myself to be a furry or what it might be like to be a furry.*

#### **Category 4: Childhood/Adolescence/Adult**

*4. I am very close to my childhood feelings.*

*40. I have definite plans for my future. I can lay out pretty well what I expect*

*year by year for the next few years.*

The modified questions are:

*4. I am very close to my childhood feelings when using Second Life.*

*40. I have definite plans for my future logins in Second Life. I can lay out pretty well what I expect year by year for the next few years.*

#### **Category 5: Interpersonal**

*53. When I get involved with someone, we sometimes get too close.*

*103. I am a very open person.*

The modified questions are:

*53. When I get involved with someone in Second Life, we sometimes get too close.*

*103. In Second Life I am a very open person.*

**Category 6: Sensitivity**

*6. I am very sensitive to other people's feelings.*

*42. I am unusually sensitive to loud noises and bright lights.*

The modified questions are:

*6. While in Second Life I am very sensitive to other avatar's feelings.*

*42. While in Second Life I am unusually sensitive to loud noises and bright lights.*

#### **Category 7: Neat/Exact/Precise**

*19. I keep my desk and work table neat and well organized.*

*43. I am good at keeping accounts and keeping track of my money.*

In *Second Life* each user account has an inventory where the user can store various items such as clothing or objects.

The modified questions are:

**Category 11: Peoples/Nations/Groups**

*and people who are considered psychotic or crazy.*

are determined to have "Thin boundaries."

*are considered psychotic or crazy.*

The modified questions are:

**Category 12: Beauty/Truth**

The modified questions are:

*rules are as soon as possible.*

*as soon as possible.*

*11. People of different nations are basically very much alike.*

*10. In Second Life, everyone should have a definite place and a specific role.*

*36. Either you are telling the truth or you are lying; that's all there is to it.*

*36. Either you are telling the truth or you are lying; that's all there is to it.*

*58. In Second Life, a good relationship is one in which everything is clearly defined and spelled out.*

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*105. There are no sharp dividing lines between normal people, people with problems, and people who*

*105. In Second Life there are no sharp dividing lines between normal people, people with problems,*

*76. When I am in a new situation, I try to find out precisely what is going on and what the rules are*

*76. When I am in a new sim in Second Life, I try to find out precisely what is going on and what the*

A subject's score is obtained by adding up all the scores (0-4) for all items. Some items are scored backwards i.e. an answer of "0" is scored as 4, "1" is scored as 3, "2" is scored as 2, "3" is scored as 1, and "4" is scored as 0. A reverse logic is built in to the questionnaire design so respondents need to think about each response instead of answering mechanically. A subject with a low score is interpreted as having "Thick boundaries" and those with higher scores

The prediction would be that subjects with thick boundaries would keep the domains of the real and the virtual clearly separate. It would also be expected that subjects whose scores are low would be able to quickly navigate back and forth and still maintain the boundaries. Subjects with thin boundaries would possibly experience spill over effects from one domain to another. Subjects with thick boundaries will be on the "focused waking thought" end of the "wake-dreaming continuum" which is characterized by "sol‐ id, divisions, categorizations." Those subjects with thin boundaries are on the "Dream‐ ing" end of the continuum characterized as "merging, condensation, loosening of categories." Hartmann et al. (2001) notes: "… people with thick boundaries spend more time and find themselves more comfortable at the left-hand end of our continuum in‐ volved in focused waking. They can be considered, "thought people," whereas the peo‐

*11. In Second Life people from different sims, groups and regions are basically very much alike.*

The currency of Second Life is called Lindens and can be purchased using real money. Questions 19 and 43 can be modified as:

*19. With my Second Life account I keep my inventory and folders neat and well organized.*

*43. I am good at keeping accounts and keeping track of my Lindens in Second Life.*

#### **Category 8: Edges/Lines/Clothing**

*32. I like heavy, solid clothing.*

*44. I like stories that have a definite beginning, middle, and end.*

The modified questions are:

*32. When in Second Life I like clothing to have a heavy, solid look.*

*44. I like stories that have a definite beginning, middle, and end.*

#### **Category 9: Opinions re Children, etc.**

*33. Children and adults have a lot in common. They should give themselves a chance to be together without any strict roles.*

*56. I think a good teacher must remain in part a child.*

**Table 3.** Sample Items by Category

The following modification is problematic as Linden Labs (makers of *Second Life*) found it necessary to age segregate users by creating a separate but equal version of *Second Life* for teens. In fact underage role-playing is prohibited in Second Life for adults. The modified questions are:

*33. Children and adults have a lot in common. In Second Life they should give themselves a chance to be together without any strict roles.*

*56. I think a good mentor must remain in part a child.*

#### **Category 10: Organizations**

*10. In an organization, everyone should have a definite place and a specific role.*

*58. A good relationship is one in which everything is clearly defined and spelled out.*

### The modified questions are:

*6. I am very sensitive to other people's feelings.*

168 Mental Disorders - Theoretical and Empirical Perspectives

The modified questions are:

**Category 7: Neat/Exact/Precise**

**Category 8: Edges/Lines/Clothing**

**Category 9: Opinions re Children, etc.**

**Table 3.** Sample Items by Category

*be together without any strict roles.*

**Category 10: Organizations**

*56. I think a good mentor must remain in part a child.*

*10. In an organization, everyone should have a definite place and a specific role.*

*58. A good relationship is one in which everything is clearly defined and spelled out.*

questions are:

*56. I think a good teacher must remain in part a child.*

*32. I like heavy, solid clothing.*

The modified questions are:

modified as:

*roles.*

*42. I am unusually sensitive to loud noises and bright lights.*

*19. I keep my desk and work table neat and well organized.*

*6. While in Second Life I am very sensitive to other avatar's feelings.*

*43. I am good at keeping accounts and keeping track of my money.*

*44. I like stories that have a definite beginning, middle, and end.*

*32. When in Second Life I like clothing to have a heavy, solid look. 44. I like stories that have a definite beginning, middle, and end.*

*42. While in Second Life I am unusually sensitive to loud noises and bright lights.*

*19. With my Second Life account I keep my inventory and folders neat and well organized.*

*43. I am good at keeping accounts and keeping track of my Lindens in Second Life.*

In *Second Life* each user account has an inventory where the user can store various items such as clothing or objects. The currency of Second Life is called Lindens and can be purchased using real money. Questions 19 and 43 can be

*33. Children and adults have a lot in common. They should give themselves a chance to be together without any strict*

The following modification is problematic as Linden Labs (makers of *Second Life*) found it necessary to age segregate users by creating a separate but equal version of *Second Life* for teens. In fact underage role-playing is prohibited in Second Life for adults. The modified

*33. Children and adults have a lot in common. In Second Life they should give themselves a chance to*

*10. In Second Life, everyone should have a definite place and a specific role.*

*58. In Second Life, a good relationship is one in which everything is clearly defined and spelled out.*

### **Category 11: Peoples/Nations/Groups**

*11. People of different nations are basically very much alike.*

*105. There are no sharp dividing lines between normal people, people with problems, and people who are considered psychotic or crazy.*

The modified questions are:

*11. In Second Life people from different sims, groups and regions are basically very much alike.*

*105. In Second Life there are no sharp dividing lines between normal people, people with problems, and people who are considered psychotic or crazy.*

### **Category 12: Beauty/Truth**

*36. Either you are telling the truth or you are lying; that's all there is to it.*

*76. When I am in a new situation, I try to find out precisely what is going on and what the rules are as soon as possible.*

The modified questions are:

*36. Either you are telling the truth or you are lying; that's all there is to it.*

*76. When I am in a new sim in Second Life, I try to find out precisely what is going on and what the rules are as soon as possible.*

A subject's score is obtained by adding up all the scores (0-4) for all items. Some items are scored backwards i.e. an answer of "0" is scored as 4, "1" is scored as 3, "2" is scored as 2, "3" is scored as 1, and "4" is scored as 0. A reverse logic is built in to the questionnaire design so respondents need to think about each response instead of answering mechanically. A subject with a low score is interpreted as having "Thick boundaries" and those with higher scores are determined to have "Thin boundaries."

The prediction would be that subjects with thick boundaries would keep the domains of the real and the virtual clearly separate. It would also be expected that subjects whose scores are low would be able to quickly navigate back and forth and still maintain the boundaries. Subjects with thin boundaries would possibly experience spill over effects from one domain to another. Subjects with thick boundaries will be on the "focused waking thought" end of the "wake-dreaming continuum" which is characterized by "sol‐ id, divisions, categorizations." Those subjects with thin boundaries are on the "Dream‐ ing" end of the continuum characterized as "merging, condensation, loosening of categories." Hartmann et al. (2001) notes: "… people with thick boundaries spend more time and find themselves more comfortable at the left-hand end of our continuum in‐ volved in focused waking. They can be considered, "thought people," whereas the peo‐ ple with thinner boundaries are more comfortable at the other end of the continuum and can be thought of as "dream people," although these terms are obviously an over-simpli‐ fication." The authors acknowledge at one time or another individuals can exhibit both thin and thick boundaries. Most individuals experience the different aspects of the "wake-dreaming continuum" during the course of entire day.

**Author details**

**References**

Gregory Patrick Garvey

Quinnipiac University, Hamden, USA

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sa.com/facts/index.asp)

London: Harper and Row.

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*nition, and Personality*, 26, 101-115.

millan.

Chicago: University of Chicago Press.

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[9] Goffman, E. (1974). Frame Analysis: An Essay on the Organization of Experience.

[10] Hartmann, E., Harrison, R., Zborowski, M. (2001). Boundaries in the Mind: Past Re‐ search and Future Directions. *North American Journal of Psychology.* 3: 347-368.

[11] Hartmann, E., Kunzendorf, R. (2006–2007). Boundaries and Dreams. *Imagination, Cog‐*

[12] Hartmann, E. (1989). Boundaries of dreams, boundaries of dreamers: thin & thick boundaries as a new personality dimension. *Psychiatric Journal of the University of Ot‐*

Virtually Human. Princeton and Oxford: Princeton University Press.

*sciousness II Special Issue.* Ed. Charles Whitehead. 17(7–8), 139-155.

Subjects with thin boundaries might be predicted to experience spill over effects such as daydreaming about the virtual world or perhaps confusing dreams about the virtual world with actual experiences as a user of that virtual world. However the BQ is not able to deter‐ mine exactly what those spill over effects might be, rather it predicts the tendency for a sub‐ ject to behave in a manner consistent with thin or thick boundaries. In fact it really is a measure of self-assessment of attitudes in regard to each of the identified categories. To de‐ termine how a subject actually behaves, what they perceive, whether or not there are spill over effects with daydreams or dream recall between the domains of the real and virtual likely requires another research methodology. In related dream research Hartmann employs a qualitative approach where subjects provide written descriptions of dreams. Such method‐ ologies may get at other details that quantitative measures miss.

As part of a theory of dreams Hartmann introduces the concept of a Central Image (Hart‐ mann & Kunzendorf 2006-7) or Contextualizing Image (Hartmann et al. 2001) that domi‐ nates in "big" and generally memorable dreams. The CI is often the feature that is readily remembered about a dream. Individual with "thin boundaries" tend to remember their dreams while individuals with "thick boundaries" tend to not remember their dreams. Do users of virtual worlds with thin boundaries have dreams where there is a high intensity Central Image based on their experiences in Second Life?

### **5. Conclusion**

To make real progress in understanding the complex nature of the borders and boundaries that separate the real from the virtual necessitates a multifaceted approach. A new "boun‐ dary questionnaire" is one step toward further study. There remains a broader question. In an age where new technologies such as augmented reality blur the boundaries of the real and virtual how do we achieve a consensus about norms of mental health against which we make judgments about what is to be considered deviations from that norm? Since the period of the enlightenment science has been the answer. But today we live in era of climate change denial, political campaigns that ignore "fact checkers", the rise of religious extremism where competing versions of reality clash. If we add on to this the overlay of virtual worlds and augmented realities, along the real possibility of malware and cyber attacks that might dis‐ tort what is heard and seen, where does it leave the rational understanding of the "real?" How do we determine if "reality testing is intact?" And whose reality is it?

### **Author details**

ple with thinner boundaries are more comfortable at the other end of the continuum and can be thought of as "dream people," although these terms are obviously an over-simpli‐ fication." The authors acknowledge at one time or another individuals can exhibit both thin and thick boundaries. Most individuals experience the different aspects of the

Subjects with thin boundaries might be predicted to experience spill over effects such as daydreaming about the virtual world or perhaps confusing dreams about the virtual world with actual experiences as a user of that virtual world. However the BQ is not able to deter‐ mine exactly what those spill over effects might be, rather it predicts the tendency for a sub‐ ject to behave in a manner consistent with thin or thick boundaries. In fact it really is a measure of self-assessment of attitudes in regard to each of the identified categories. To de‐ termine how a subject actually behaves, what they perceive, whether or not there are spill over effects with daydreams or dream recall between the domains of the real and virtual likely requires another research methodology. In related dream research Hartmann employs a qualitative approach where subjects provide written descriptions of dreams. Such method‐

As part of a theory of dreams Hartmann introduces the concept of a Central Image (Hart‐ mann & Kunzendorf 2006-7) or Contextualizing Image (Hartmann et al. 2001) that domi‐ nates in "big" and generally memorable dreams. The CI is often the feature that is readily remembered about a dream. Individual with "thin boundaries" tend to remember their dreams while individuals with "thick boundaries" tend to not remember their dreams. Do users of virtual worlds with thin boundaries have dreams where there is a high intensity

To make real progress in understanding the complex nature of the borders and boundaries that separate the real from the virtual necessitates a multifaceted approach. A new "boun‐ dary questionnaire" is one step toward further study. There remains a broader question. In an age where new technologies such as augmented reality blur the boundaries of the real and virtual how do we achieve a consensus about norms of mental health against which we make judgments about what is to be considered deviations from that norm? Since the period of the enlightenment science has been the answer. But today we live in era of climate change denial, political campaigns that ignore "fact checkers", the rise of religious extremism where competing versions of reality clash. If we add on to this the overlay of virtual worlds and augmented realities, along the real possibility of malware and cyber attacks that might dis‐ tort what is heard and seen, where does it leave the rational understanding of the "real?"

How do we determine if "reality testing is intact?" And whose reality is it?

"wake-dreaming continuum" during the course of entire day.

170 Mental Disorders - Theoretical and Empirical Perspectives

ologies may get at other details that quantitative measures miss.

Central Image based on their experiences in Second Life?

**5. Conclusion**

Gregory Patrick Garvey

Quinnipiac University, Hamden, USA

### **References**


**Chapter 8**

**Somatic Symptom Disorder**

Lesley A. Allen and Robert L. Woolfolk

http://dx.doi.org/10.5772/52431

experiential emotion-focused therapy.

**1. Introduction**

Additional information is available at the end of the chapter

In the chapter we present our model of treatment for somatic symptom disorder. We begin with a brief history of somatic symptom disorder followed by a discussion of theory and research on it. Finally, we describe our psychosocial treatment for somatic symptom disorder and related disorders, which employs methods from both cognitive behavioral therapy and

Physical symptoms with uncertain medical explanations are some of the most common presentations in primary care. As many as 25% of visits to primary care physicians are prompted by physical symptoms that lack any clear organic pathology [1]. Although some patients with medically unexplained physical symptoms experience mild and/or transient discomfort, others experience substantial discomfort, distress, and impairment in functioning [2,3]. It is these patients, those with impairing physical symptoms of unknown etiology, who

Medicine has long recognized a group of patients with medically unexplained physical symptoms (MUPS) and excessive health concerns. Originally theorized to be caused by a wandering uterus that produced discomfort and pain, MUPS were first described by ancient

It was not until 1980 and the publication of DSM-III that the terms somatization and somato‐ form were introduced for physical symptoms that were medically unexplained [4]. According to DSM-III somatization disorder was characterized by "recurrent and multiple somatic complaints of several years' duration for which medical attention had been sought but which are apparently not due to any physical disorder" [4]. Also in that volume the diagnostic category of somatoform disorders was created and subsumed somatization disorder, conver‐ sion disorder, psychogenic pain disorder, hypochondriasis, and a residual category, atypical somatoform disorder for other disturbances with a presentation of MUPS [4]. Conversion

and reproduction in any medium, provided the original work is properly cited.

© 2013 Allen and Woolfolk; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

are often refractory to standard medical treatment and overuse medical services [2].

Egyptians and first labeled hysteria by the ancient Greeks.


### **Chapter 8**

## **Somatic Symptom Disorder**

Lesley A. Allen and Robert L. Woolfolk

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/52431

### **1. Introduction**

[13] Hartmann, E. (1991). Boundaries in the Mind. New York: Basic Books.

veils-augmented-reality-glasses-its-vision-of-the-post-pc-era/

[16] KZERO WORLDWIDE Retrieved 8/5/2012 from http://www.kzero.co.uk/

Beacon Press.

172 Mental Disorders - Theoretical and Empirical Perspectives

2008.

bridge: MIT Press.

Free Press.

*Disease and Treatment,* 4(5), 977–986.

[20] *Second Life.* Retrieved 7/19/2012 from http://secondlife.com/

[14] Hill, D. J., *Google Unveils Augmented-Reality Glasses, Its Vision Of The Post-PC Era*. April 5, 2012. Retrieved 9/2/2012. http://singularityhub.com/2012/04/05/google-un‐

[15] Huizinga, J. (1955). Homo Ludens: A Study of the Play Element in Culture. Boston:

[17] Mula, M., Pini, S., Calugi, S., Preve, M., Masini, M., Giovannini, I., Conversano, C., Rucci, P., and Cassano, G. B. (2008), Validity and reliability of the Structured Clinical Interview for Depersonalization–Derealization Spectrum (SCI-DER), *Neuropsychiatric*

[18] Pew Research Center. (2008). Teens, Video Games and Civics. Retrieved 8/30/2012 from http://pewresearch.org/pubs/953/teens-video-games-and-civics. September 16,

[19] Salen, K. & Zimmerman, E. (2003). Rules of Play: Game Design Fundamentals. Cam‐

[21] Second Life Wikia. (n.d.). Glossary. Retrieved 8/25/2012 from http://secon‐ dlife.wikia.com/index.php?title=Category:Glossary&until=Popular+Places

[22] Zerubavel, E. (1991). The fine line: Making distinctions in everyday life. New York:

In the chapter we present our model of treatment for somatic symptom disorder. We begin with a brief history of somatic symptom disorder followed by a discussion of theory and research on it. Finally, we describe our psychosocial treatment for somatic symptom disorder and related disorders, which employs methods from both cognitive behavioral therapy and experiential emotion-focused therapy.

Physical symptoms with uncertain medical explanations are some of the most common presentations in primary care. As many as 25% of visits to primary care physicians are prompted by physical symptoms that lack any clear organic pathology [1]. Although some patients with medically unexplained physical symptoms experience mild and/or transient discomfort, others experience substantial discomfort, distress, and impairment in functioning [2,3]. It is these patients, those with impairing physical symptoms of unknown etiology, who are often refractory to standard medical treatment and overuse medical services [2].

Medicine has long recognized a group of patients with medically unexplained physical symptoms (MUPS) and excessive health concerns. Originally theorized to be caused by a wandering uterus that produced discomfort and pain, MUPS were first described by ancient Egyptians and first labeled hysteria by the ancient Greeks.

It was not until 1980 and the publication of DSM-III that the terms somatization and somato‐ form were introduced for physical symptoms that were medically unexplained [4]. According to DSM-III somatization disorder was characterized by "recurrent and multiple somatic complaints of several years' duration for which medical attention had been sought but which are apparently not due to any physical disorder" [4]. Also in that volume the diagnostic category of somatoform disorders was created and subsumed somatization disorder, conver‐ sion disorder, psychogenic pain disorder, hypochondriasis, and a residual category, atypical somatoform disorder for other disturbances with a presentation of MUPS [4]. Conversion

© 2013 Allen and Woolfolk; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

disorder was characterized by a "loss or alteration in physical functioning that suggests a physical disorder but which instead is apparently an expression of a psychological conflict or need" [4]. If the medically unexplained symptom was a pain symptom and the symptom was judged to be associated with psychological factors, the diagnosis of psychogenic pain disorder would be indicated. The essential feature of hypochondriasis was a preoccupation with the fear or belief of having a serious disease.

**2. Epidemiological findings and clinical characteristics**

as outlined in DSM-III, DSM-III-R, or DSM-IV.)

misuse health care services [2,17,18].

associated with somatization [13,18-20].

reported [3,21].

Although there is no published research on DSM-5's somatic symptom disorder, research on some of the older diagnostic categories is likely to apply. Distressing physical symptoms are common in medical clinics. As many as 20% of primary care patients have MUPS [11-13]. Epidemiological research has shown patients with MUPS to be more likely to be female, nonwhite, and less educated than patients with medically explained symptoms [13-15]. Findings on ethnicity have been less consistent across studies. In the Epidemiological Catchment Area project, examining psychiatric complaints in the general population at five sites in the United States, Hispanics were no more likely to meet criteria for somatization disorder than were non-Hispanics [15]. The World Health Organization study, conducted in primary care clinics in 14 different countries, revealed a higher incidence of somatization in Latin American countries than in the United States [13]. (Note that the terms medically unexplained symptoms (MUPS) and somatization will be used interchangeably in the remainder of this chapter. The term somatization disorder is reserved for cases meeting the full criteria for somatization disorder

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 175

Patients with MUPS often engage in dysfunctional illness behavior. When standard diagnostic evaluations fail to uncover organic pathology, patients may seek additional medical proce‐ dures, often from several different physicians. When symptoms continue unresolved, patients may switch physicians and/or treatment approaches. Patients may even subject themselves to unnecessary hospitalizations and surgeries, which introduce the risk of iatrogenic illness [16]. Patients with multiple medically unexplained symptoms have been shown to overuse and

MUPS may not only prompt excessive use of medical procedures, they may also affect patients' workplaces and households. Patients who are excessively focused on their somatic symptoms may withdraw from both productive and pleasurable activities because of discomfort, fatigue, and/or fears of exacerbating their symptoms. High levels of functional impairment have been

Comorbid psychopathology is common in patients with MUPS. Ongoing physical discomfort can be demoralizing, anxiety-provoking, and frustrating. Approximately 50% of patient with multiple MUPS meet DSM criteria for an Axis I disorder, most often depression and/or anxiety [19,21]. Also, overall severity of psychological distress, defined as the number of psychological symptoms reported, correlates positively with the number of functional somatic symptoms

A growing body of research indicates certain cognitive styles may be associated with somati‐ zation. Barksy suggested patients with unexplained physical symptoms have a tendency to amplify somatosensory information; that is, they are hypersensitive to bodily sensations which are experienced as intense, noxious, and disturbing [22]. Other researchers have shown that patients with MUPS form negative cognitive appraisals of their physical sensations, thinking catastrophically about their symptoms [23] and/or overestimating the medical severity of symptoms after a medical evaluation [24]. Research demonstrating that memories and

Both DSM-III-R [5] and DSM-IV [6] used similar diagnostic labels and criteria to those used in DSM-III for presentations predominated by MUPS. An additional diagnostic label, undiffer‐ entiated somatoform disorder, was introduced in DSM-III-R and retained in DSM-IV for cases of MUPS but that did not meet all the criteria of somatization disorder. This less severe form of somatization, undifferentiated somatoform disorder, was characterized by one or more MUPS that lasted for at least 6 months [5,6].

Somatic symptom disorder is a new diagnostic label proposed for DSM-5 [7]. The diagnostic criteria for somatic symptom disorder are distressing and chronic somatic symptoms and associated dysfunctional thoughts, feelings, and/or behaviors (Table 1). In contrast to earlier editions of DSM, DSM-5 has shifted from emphasizing the functional status of somatic symptoms (i.e., that symptoms be medically unexplained) to the maladaptive thoughts, feelings, and behaviors related to somatic symptoms. According to DSM-5's Somatic Symptom Disorders Work Group, unlike the criteria for somatization disorder and other somatoform disorders described in earlier editions of DSM, the criteria for somatic symptom disorder require the presence of specific characteristics rather than the absence of characteristics (i.e., evidence of organic basis) and are more reliably determined [7]. Research has shown significant variability among physicians in their tendency to rate symptoms as medically unexplained [8]. Also, patient reports of the functional status of symptoms are unreliable [9]. Thus, the diagnosis no longer requires evidence that symptoms are medically unexplained. In addition to elimi‐ nating the assessment of the organic basis of the symptoms, the Somatic Symptom Disorders Work Group has proposed a new, less controversial label for somatically-focused presenta‐ tions [7]. It seems the diagnoses of somatization and somatoform disorder carried pejorative connotations [10].

A. Somatic Symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.


**Table 1.** Proposed DSM-5 Diagnostic Criteria for Somatic Symptom Disorder

### **2. Epidemiological findings and clinical characteristics**

disorder was characterized by a "loss or alteration in physical functioning that suggests a physical disorder but which instead is apparently an expression of a psychological conflict or need" [4]. If the medically unexplained symptom was a pain symptom and the symptom was judged to be associated with psychological factors, the diagnosis of psychogenic pain disorder would be indicated. The essential feature of hypochondriasis was a preoccupation with the

Both DSM-III-R [5] and DSM-IV [6] used similar diagnostic labels and criteria to those used in DSM-III for presentations predominated by MUPS. An additional diagnostic label, undiffer‐ entiated somatoform disorder, was introduced in DSM-III-R and retained in DSM-IV for cases of MUPS but that did not meet all the criteria of somatization disorder. This less severe form of somatization, undifferentiated somatoform disorder, was characterized by one or more

Somatic symptom disorder is a new diagnostic label proposed for DSM-5 [7]. The diagnostic criteria for somatic symptom disorder are distressing and chronic somatic symptoms and associated dysfunctional thoughts, feelings, and/or behaviors (Table 1). In contrast to earlier editions of DSM, DSM-5 has shifted from emphasizing the functional status of somatic symptoms (i.e., that symptoms be medically unexplained) to the maladaptive thoughts, feelings, and behaviors related to somatic symptoms. According to DSM-5's Somatic Symptom Disorders Work Group, unlike the criteria for somatization disorder and other somatoform disorders described in earlier editions of DSM, the criteria for somatic symptom disorder require the presence of specific characteristics rather than the absence of characteristics (i.e., evidence of organic basis) and are more reliably determined [7]. Research has shown significant variability among physicians in their tendency to rate symptoms as medically unexplained [8]. Also, patient reports of the functional status of symptoms are unreliable [9]. Thus, the diagnosis no longer requires evidence that symptoms are medically unexplained. In addition to elimi‐ nating the assessment of the organic basis of the symptoms, the Somatic Symptom Disorders Work Group has proposed a new, less controversial label for somatically-focused presenta‐ tions [7]. It seems the diagnoses of somatization and somatoform disorder carried pejorative

A. Somatic Symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in

B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At

1. Disproportionate and persistent thoughts about the seriousness of one's symptoms

3. Excessive time and energy devoted to these symptoms or health concerns C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is

2. Persistently high level of anxiety about health or symptoms

**Table 1.** Proposed DSM-5 Diagnostic Criteria for Somatic Symptom Disorder

fear or belief of having a serious disease.

174 Mental Disorders - Theoretical and Empirical Perspectives

MUPS that lasted for at least 6 months [5,6].

connotations [10].

least one of the following must be present.

persistent (typically "/> 6 months).

daily life.

Although there is no published research on DSM-5's somatic symptom disorder, research on some of the older diagnostic categories is likely to apply. Distressing physical symptoms are common in medical clinics. As many as 20% of primary care patients have MUPS [11-13]. Epidemiological research has shown patients with MUPS to be more likely to be female, nonwhite, and less educated than patients with medically explained symptoms [13-15]. Findings on ethnicity have been less consistent across studies. In the Epidemiological Catchment Area project, examining psychiatric complaints in the general population at five sites in the United States, Hispanics were no more likely to meet criteria for somatization disorder than were non-Hispanics [15]. The World Health Organization study, conducted in primary care clinics in 14 different countries, revealed a higher incidence of somatization in Latin American countries than in the United States [13]. (Note that the terms medically unexplained symptoms (MUPS) and somatization will be used interchangeably in the remainder of this chapter. The term somatization disorder is reserved for cases meeting the full criteria for somatization disorder as outlined in DSM-III, DSM-III-R, or DSM-IV.)

Patients with MUPS often engage in dysfunctional illness behavior. When standard diagnostic evaluations fail to uncover organic pathology, patients may seek additional medical proce‐ dures, often from several different physicians. When symptoms continue unresolved, patients may switch physicians and/or treatment approaches. Patients may even subject themselves to unnecessary hospitalizations and surgeries, which introduce the risk of iatrogenic illness [16]. Patients with multiple medically unexplained symptoms have been shown to overuse and misuse health care services [2,17,18].

MUPS may not only prompt excessive use of medical procedures, they may also affect patients' workplaces and households. Patients who are excessively focused on their somatic symptoms may withdraw from both productive and pleasurable activities because of discomfort, fatigue, and/or fears of exacerbating their symptoms. High levels of functional impairment have been associated with somatization [13,18-20].

Comorbid psychopathology is common in patients with MUPS. Ongoing physical discomfort can be demoralizing, anxiety-provoking, and frustrating. Approximately 50% of patient with multiple MUPS meet DSM criteria for an Axis I disorder, most often depression and/or anxiety [19,21]. Also, overall severity of psychological distress, defined as the number of psychological symptoms reported, correlates positively with the number of functional somatic symptoms reported [3,21].

A growing body of research indicates certain cognitive styles may be associated with somati‐ zation. Barksy suggested patients with unexplained physical symptoms have a tendency to amplify somatosensory information; that is, they are hypersensitive to bodily sensations which are experienced as intense, noxious, and disturbing [22]. Other researchers have shown that patients with MUPS form negative cognitive appraisals of their physical sensations, thinking catastrophically about their symptoms [23] and/or overestimating the medical severity of symptoms after a medical evaluation [24]. Research demonstrating that memories and expectations of physical symptomatology prime future symptomatology [25] is likely to apply to somatizers.

Relaxation training may be employed to teach patients to use progressive muscle relaxation and/or diaphragmatic breathing to reduce physiologic arousal. Behavioral activation/activity regulation promotes increases in pleasurable and meaningful activities to modify the tendency of these patients to withdraw from important aspects of their lives. Also, activity pacing is taught so that patients will increase their activity levels gradually without exhausting or injuring themselves. The cognitive restructuring component aims to help patients combat dysfunctional cognitive tendencies. Communication skills, especially assertiveness training, are taught to address the social disability that has been reported by somatizers [39]. Finally, patients' environments are examined for factors that reinforce their physical symptoms. Those factors are targeted for change. In some treatment protocols the patient's spouse/partner is invited to participate in treatment sessions. Given the important role that spouses play in reinforcing patients' expression of pain and pain behavior [40], spousal behaviors that

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 177

The financial costs and associated suffering and disability of somatization make it a public health concern. Given that many patients with MUPS fail to respond to standard medical care, alternative treatments have been developed. Although different psychosocial interventions have been used to treat somatization, some administered by primary physicians/clinicians and others administered by mental health providers, most approaches that have been examined in randomized controlled clinical trials have been theoretically grounded in the biopsychoso‐ cial model described above. Cognitive behavioral therapy (CBT) is the form of psychotherapy most often examined. Also, a number of different approaches to retraining primary care

The first published randomized controlled trials on CBT for somatization included patients presenting with relatively mild levels of somatization, patients presenting with at least one psychosomatic symptom. The treatment protocols included identifying and restructuring dysfunctional cognitions, encouraging patients to reengage in avoided activities, problemsolving, and relaxation training [41,42]. In the first study patients treated with 6 to 16 sessions of individually-administered CBT showed significantly greater improvement in their psycho‐ somatic complaints than did patients treated with standard medical care [41]. The other study found an 8-session group CBT superior to a waiting-list control condition in reducing physical symptoms and hypochondriacal beliefs [42]. In both studies improvements were observed after treatment as well as six months later [41,42]. Both of these studies were conducted in

Two more recently published randomized controlled trials examined the efficacy of CBT for somatization with patients presenting with more severe somatization than the earlier trials. One study enrolled patients with at least four somatization symptoms [43]. The other trial

physicians or integrating CBT into primary care have been investigated.

primary care offices, the setting where somatization is most likely to be seen.

reinforce patients' symptoms may be modified.

**4. Treatment outcome research**

**4.1. Psychotherapy**

Two personality styles have also been associated with somatization. Patients with MUPS tend to score high on scales of neuroticism and negative affect [26]. Alexithymia, defined as having difficulty identifying and describing one's emotions, is common in somatization [27-29]. Thus, we see somatization

patients as individuals who may be emotionally and physically hyper-reactive while having insufficient insight into their emotional and physical sensations.

### **3. Biopsychosocial model**

The biopsychosocial model of illness, proposed by George Engel [30], suggests that illness is a complex entity involving the interaction of biological, psychological, and social factors. A biopsychosocial conceptualization of somatic symptom disorder emphasizes the interaction among biology, cognition, emotion, behavior, and environment [31,32].

There is a growing body of research that supports key features of the biopsychosocial model of somatic symptom disorder. Genetic and early environmental factors may predispose individuals to experiencing somatic symptomatology [33]. Patients presenting with multiple somatic symptoms have higher levels of physiological arousal and are less likely to habituate to a stressful task than control subjects [34]. These predisposing factors may be compounded by the dysfunctional attentional and cognitive tendencies described in the previous section. The more attention one focuses upon his or her body, the more likely one is to report somatic symptoms [35,36].

Dysfunctional cognitions may elicit negative emotions or be elicited by negative emotions [37]. This cognition-emotion cycle may interact in a complex fashion with maladaptive behaviors. For example, thoughts of possible illness give rise to feelings of anxiety, dysphoria, and frustration, which are likely to generate and maintain physiological arousal and physical symptomatology. Intending to prevent injury or exacerbation of symptoms, these patients typically withdraw from their normal activities [2,3]. Such time away from activities provides opportunities for additional attention to be focused upon one's physical health. Furthermore, patients suffering from these physical symptoms, distorted cognitions, and negative affect may seek repeated contact with physicians and request medical tests. Pain catastrophizing has been associated with medical utilization and disability [38]. Physicians, in turn, attempting to conduct thorough evaluations and avoid malpractice suits, may encourage somatizing behavior by ordering unnecessary diagnostic procedures. Chronic medical testing may ingrain patients in the "sick role" and reinforce somatizers' maladaptive belief that any physical symptom indicates organic pathology. Also, unnecessary medical procedures, if implemented, may result in iatrogenic illness.

A biopsychosocial model of medically unexplained symptoms leads to specific psychosocial treatment strategies that include behavioral, cognitive, and interpersonal interventions. Relaxation training may be employed to teach patients to use progressive muscle relaxation and/or diaphragmatic breathing to reduce physiologic arousal. Behavioral activation/activity regulation promotes increases in pleasurable and meaningful activities to modify the tendency of these patients to withdraw from important aspects of their lives. Also, activity pacing is taught so that patients will increase their activity levels gradually without exhausting or injuring themselves. The cognitive restructuring component aims to help patients combat dysfunctional cognitive tendencies. Communication skills, especially assertiveness training, are taught to address the social disability that has been reported by somatizers [39]. Finally, patients' environments are examined for factors that reinforce their physical symptoms. Those factors are targeted for change. In some treatment protocols the patient's spouse/partner is invited to participate in treatment sessions. Given the important role that spouses play in reinforcing patients' expression of pain and pain behavior [40], spousal behaviors that reinforce patients' symptoms may be modified.

### **4. Treatment outcome research**

The financial costs and associated suffering and disability of somatization make it a public health concern. Given that many patients with MUPS fail to respond to standard medical care, alternative treatments have been developed. Although different psychosocial interventions have been used to treat somatization, some administered by primary physicians/clinicians and others administered by mental health providers, most approaches that have been examined in randomized controlled clinical trials have been theoretically grounded in the biopsychoso‐ cial model described above. Cognitive behavioral therapy (CBT) is the form of psychotherapy most often examined. Also, a number of different approaches to retraining primary care physicians or integrating CBT into primary care have been investigated.

#### **4.1. Psychotherapy**

expectations of physical symptomatology prime future symptomatology [25] is likely to apply

Two personality styles have also been associated with somatization. Patients with MUPS tend to score high on scales of neuroticism and negative affect [26]. Alexithymia, defined as having difficulty identifying and describing one's emotions, is common in somatization [27-29]. Thus,

patients as individuals who may be emotionally and physically hyper-reactive while having

The biopsychosocial model of illness, proposed by George Engel [30], suggests that illness is a complex entity involving the interaction of biological, psychological, and social factors. A biopsychosocial conceptualization of somatic symptom disorder emphasizes the interaction

There is a growing body of research that supports key features of the biopsychosocial model of somatic symptom disorder. Genetic and early environmental factors may predispose individuals to experiencing somatic symptomatology [33]. Patients presenting with multiple somatic symptoms have higher levels of physiological arousal and are less likely to habituate to a stressful task than control subjects [34]. These predisposing factors may be compounded by the dysfunctional attentional and cognitive tendencies described in the previous section. The more attention one focuses upon his or her body, the more likely one is to report somatic

Dysfunctional cognitions may elicit negative emotions or be elicited by negative emotions [37]. This cognition-emotion cycle may interact in a complex fashion with maladaptive behaviors. For example, thoughts of possible illness give rise to feelings of anxiety, dysphoria, and frustration, which are likely to generate and maintain physiological arousal and physical symptomatology. Intending to prevent injury or exacerbation of symptoms, these patients typically withdraw from their normal activities [2,3]. Such time away from activities provides opportunities for additional attention to be focused upon one's physical health. Furthermore, patients suffering from these physical symptoms, distorted cognitions, and negative affect may seek repeated contact with physicians and request medical tests. Pain catastrophizing has been associated with medical utilization and disability [38]. Physicians, in turn, attempting to conduct thorough evaluations and avoid malpractice suits, may encourage somatizing behavior by ordering unnecessary diagnostic procedures. Chronic medical testing may ingrain patients in the "sick role" and reinforce somatizers' maladaptive belief that any physical symptom indicates organic pathology. Also, unnecessary medical procedures, if implemented,

A biopsychosocial model of medically unexplained symptoms leads to specific psychosocial treatment strategies that include behavioral, cognitive, and interpersonal interventions.

insufficient insight into their emotional and physical sensations.

among biology, cognition, emotion, behavior, and environment [31,32].

to somatizers.

we see somatization

symptoms [35,36].

may result in iatrogenic illness.

**3. Biopsychosocial model**

176 Mental Disorders - Theoretical and Empirical Perspectives

The first published randomized controlled trials on CBT for somatization included patients presenting with relatively mild levels of somatization, patients presenting with at least one psychosomatic symptom. The treatment protocols included identifying and restructuring dysfunctional cognitions, encouraging patients to reengage in avoided activities, problemsolving, and relaxation training [41,42]. In the first study patients treated with 6 to 16 sessions of individually-administered CBT showed significantly greater improvement in their psycho‐ somatic complaints than did patients treated with standard medical care [41]. The other study found an 8-session group CBT superior to a waiting-list control condition in reducing physical symptoms and hypochondriacal beliefs [42]. In both studies improvements were observed after treatment as well as six months later [41,42]. Both of these studies were conducted in primary care offices, the setting where somatization is most likely to be seen.

Two more recently published randomized controlled trials examined the efficacy of CBT for somatization with patients presenting with more severe somatization than the earlier trials. One study enrolled patients with at least four somatization symptoms [43]. The other trial enrolled participants who complained of five or more unexplained physical symptoms [44]. In both studies patients were identified and treated with CBT in primary care. Treatment protocols were similar to Lidbeck's [42] and Speckens et al., [41] with the addition of involving the patient's spouse or other family member in treatment [43,44]. Spouses are included to provide additional information regarding patients' functioning, to facilitate patients' engage‐ ment in and compliance with treatment, and to help reduce reinforcement of illness behavior. Findings from both trials show individual CBT coincided with greater reductions in somatic complaints than did standard medical care [43,44]. CBT was associated with a reduction in the number of physician visits in one study [44].

such as "your symptoms are all in your head." Patients whose primary physicians had received the consultation letter experienced better health outcomes, such as physical functioning and cost of medical care, than those whose physicians had not received the letter. The results were replicated in three additional studies, one study using patients meeting criteria for full somatization disorder [48] and two studies using patients with more moderate levels of

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 179

Some investigators have attempted to train primary care physicians to better detect somati‐ zation and to incorporate cognitive and behavioral techniques into their treatment of these patients. Five groups of investigators have reported controlled clinical trials on the effects of such physician training [51-55]. The two studies providing the most extensive physician training (20-25 hours) resulted in no association between physician training and patients' symptomatology, functioning, or quality of life [51,55]. Three other studies found less intensive physician training programs, 12 hours [52] or 1 day [54] or six hours [53] to coincide with no clear improvement in somatization symptomatology; however, Rief and colleagues did find their training to result in fewer health care visits for the 6 months subsequent to training [54].

One other study examined the effect of training primary care clinicians to identify and treat somatization using a biopsychosocial model [56]. This study involved the most intensive such training programs studied, one entailing 84 hours over 10 weeks. Nurse practitioners were trained to provide a year-long 12-session multidimensional intervention in primary care that incorporated biopsychosocial conceptualizations, behavioral recommendations, and medica‐ tion management of somatization. Patients who received treatment from these trained nurses reported modest improvements on self-report scales of mental health such as mood and energy and physical functioning. A post hoc analysis was interpreted by the study's investigators as suggesting improvements were attributable to more frequent and appropriate use of antide‐

Some researchers have studied the effects of a collaborative care model of treatment, in which mental health professionals work together with medical practitioners in the primary care setting [57,58]. The one study investigating the efficacy of such a model for the treatment of somatization had psychiatrists provide primary care physicians and their staff with training on the diagnosis and treatment of somatization and comorbid psychopathology [59]. Also, the psychiatrist provided case-specific consultations to primary physicians regarding referrals for CBT and/or psychiatric treatment [59]. A control comparison treatment included the same training for primary care physicians and their staff by the psychiatrist without the case-specific consultation. Six months after randomization, participants whose primary care physician received psychiatric consultation reported a greater reduction in somatic symptoms and in

In all, the literature on the treatment of somatization supports the use of 6-16 sessions of CBT or ACBT administered by a mental health professional. A recent meta-analysis indicated CBT is modestly effective in reducing somatization symptomatology and minimally effective improving physical functioning [60]. To date there is no evidence that CBT reduces health care services when the cost of CBT itself is considered. Researchers have just begun to develop and

pressant medication among patients of nurses who received the training [56].

somatization [49,50].

health care visits [59].

Our researcher team published a randomized controlled trial on the efficacy of an emotionallyfocused cognitive behavioral intervention, affective cognitive behavioral therapy (ACBT) for some of the most severely disturbed patients with somatization [45]. In the study 84 patients meeting DSM-IV criteria for somatization disorder were randomly assigned to one of two conditions: [1] standard medical care or [2] a 10-session manualized individually-administered ACBT in combination with standard medical care. The treatment protocol included some of the usual components of CBT for somatization, i.e., relaxation training, activity regulation, cognitive restructuring, and interpersonal communication as well as facilitation of emotional awareness. Although the elicitation and exploration of affect is an approach rarely used in CBT, we have found this component to be a powerful clinical tool with patients who cannot or do not willingly access and experience emotion. We describe our treatment in the following sections and elsewhere in more detail [46]. Participants' symptomatology and functioning were assessed with clinician-administered instruments, self-report questionnaires, and medical records before randomization as well as 3 months, 9 months, and 15 months after randomization. Just after the completion of treatment as well as one year later, i.e., at the 15 month follow-up assessment, patients who received ACBT experienced a greater reduction in somatization and functional impairment. Substantially more participants who received ACBT than the control treatment were rated as either "very much improved" or "much improved" by a clinician who was blind to participants' treatment condition (40% vs. 5%, respectively). Also, for the 68% of the sample for whom complete medical records were reviewed, ACBT was associated with a reduction in health care costs and physician visits [45]. Thus, the study suggests ACBT can result in long-term improvements in symptomatology, functioning, and health care utilization of the most severely disturbed somatizing patients.

#### **4.2. Primary care interventions**

Given the prevalence of MUPS in primary care [1,11,12], much research has centered on primary care physicians' behavior. Smith and colleagues sent a psychiatric consultation letter to patients' primary care physicians, describing somatization disorder and providing recom‐ mendations to guide primary care [47]. The recommendations to physicians were straightfor‐ ward: (a) to schedule somatizers' appointments every 4 to 6 weeks instead of as needed appointments, (b) to conduct a physical examination in the organ system or body part relevant to the presenting complaint, (c) to avoid diagnostic procedures and surgeries unless clearly indicated by underlying somatic pathology, and (d) to avoid making disparaging statements, such as "your symptoms are all in your head." Patients whose primary physicians had received the consultation letter experienced better health outcomes, such as physical functioning and cost of medical care, than those whose physicians had not received the letter. The results were replicated in three additional studies, one study using patients meeting criteria for full somatization disorder [48] and two studies using patients with more moderate levels of somatization [49,50].

enrolled participants who complained of five or more unexplained physical symptoms [44]. In both studies patients were identified and treated with CBT in primary care. Treatment protocols were similar to Lidbeck's [42] and Speckens et al., [41] with the addition of involving the patient's spouse or other family member in treatment [43,44]. Spouses are included to provide additional information regarding patients' functioning, to facilitate patients' engage‐ ment in and compliance with treatment, and to help reduce reinforcement of illness behavior. Findings from both trials show individual CBT coincided with greater reductions in somatic complaints than did standard medical care [43,44]. CBT was associated with a reduction in the

Our researcher team published a randomized controlled trial on the efficacy of an emotionallyfocused cognitive behavioral intervention, affective cognitive behavioral therapy (ACBT) for some of the most severely disturbed patients with somatization [45]. In the study 84 patients meeting DSM-IV criteria for somatization disorder were randomly assigned to one of two conditions: [1] standard medical care or [2] a 10-session manualized individually-administered ACBT in combination with standard medical care. The treatment protocol included some of the usual components of CBT for somatization, i.e., relaxation training, activity regulation, cognitive restructuring, and interpersonal communication as well as facilitation of emotional awareness. Although the elicitation and exploration of affect is an approach rarely used in CBT, we have found this component to be a powerful clinical tool with patients who cannot or do not willingly access and experience emotion. We describe our treatment in the following sections and elsewhere in more detail [46]. Participants' symptomatology and functioning were assessed with clinician-administered instruments, self-report questionnaires, and medical records before randomization as well as 3 months, 9 months, and 15 months after randomization. Just after the completion of treatment as well as one year later, i.e., at the 15 month follow-up assessment, patients who received ACBT experienced a greater reduction in somatization and functional impairment. Substantially more participants who received ACBT than the control treatment were rated as either "very much improved" or "much improved" by a clinician who was blind to participants' treatment condition (40% vs. 5%, respectively). Also, for the 68% of the sample for whom complete medical records were reviewed, ACBT was associated with a reduction in health care costs and physician visits [45]. Thus, the study suggests ACBT can result in long-term improvements in symptomatology, functioning, and

health care utilization of the most severely disturbed somatizing patients.

Given the prevalence of MUPS in primary care [1,11,12], much research has centered on primary care physicians' behavior. Smith and colleagues sent a psychiatric consultation letter to patients' primary care physicians, describing somatization disorder and providing recom‐ mendations to guide primary care [47]. The recommendations to physicians were straightfor‐ ward: (a) to schedule somatizers' appointments every 4 to 6 weeks instead of as needed appointments, (b) to conduct a physical examination in the organ system or body part relevant to the presenting complaint, (c) to avoid diagnostic procedures and surgeries unless clearly indicated by underlying somatic pathology, and (d) to avoid making disparaging statements,

**4.2. Primary care interventions**

number of physician visits in one study [44].

178 Mental Disorders - Theoretical and Empirical Perspectives

Some investigators have attempted to train primary care physicians to better detect somati‐ zation and to incorporate cognitive and behavioral techniques into their treatment of these patients. Five groups of investigators have reported controlled clinical trials on the effects of such physician training [51-55]. The two studies providing the most extensive physician training (20-25 hours) resulted in no association between physician training and patients' symptomatology, functioning, or quality of life [51,55]. Three other studies found less intensive physician training programs, 12 hours [52] or 1 day [54] or six hours [53] to coincide with no clear improvement in somatization symptomatology; however, Rief and colleagues did find their training to result in fewer health care visits for the 6 months subsequent to training [54].

One other study examined the effect of training primary care clinicians to identify and treat somatization using a biopsychosocial model [56]. This study involved the most intensive such training programs studied, one entailing 84 hours over 10 weeks. Nurse practitioners were trained to provide a year-long 12-session multidimensional intervention in primary care that incorporated biopsychosocial conceptualizations, behavioral recommendations, and medica‐ tion management of somatization. Patients who received treatment from these trained nurses reported modest improvements on self-report scales of mental health such as mood and energy and physical functioning. A post hoc analysis was interpreted by the study's investigators as suggesting improvements were attributable to more frequent and appropriate use of antide‐ pressant medication among patients of nurses who received the training [56].

Some researchers have studied the effects of a collaborative care model of treatment, in which mental health professionals work together with medical practitioners in the primary care setting [57,58]. The one study investigating the efficacy of such a model for the treatment of somatization had psychiatrists provide primary care physicians and their staff with training on the diagnosis and treatment of somatization and comorbid psychopathology [59]. Also, the psychiatrist provided case-specific consultations to primary physicians regarding referrals for CBT and/or psychiatric treatment [59]. A control comparison treatment included the same training for primary care physicians and their staff by the psychiatrist without the case-specific consultation. Six months after randomization, participants whose primary care physician received psychiatric consultation reported a greater reduction in somatic symptoms and in health care visits [59].

In all, the literature on the treatment of somatization supports the use of 6-16 sessions of CBT or ACBT administered by a mental health professional. A recent meta-analysis indicated CBT is modestly effective in reducing somatization symptomatology and minimally effective improving physical functioning [60]. To date there is no evidence that CBT reduces health care services when the cost of CBT itself is considered. Researchers have just begun to develop and examine the effectiveness of true collaboration of cognitive behavioral therapist and primary care clinician and integration of their services.

to identify cognitive and affective characteristics of somatizing patients have found these patients to experience high rates of negative affect and to be less aware of and less able to describe thoughts and feelings than are other psychiatric patients [27-29]. Other authorities have discussed the "hysterical" emotional styles of these patients [71,72]. Our own impression is that whereas some somatizers manifest attenuated emotional processing and obliviousness to affect, others seem to have exaggerated emotional reactions. Some patients display each style, at different times. Contemporary theory in cognitive neuroscience suggests that emo‐ tional processing provides an important source of information about one's reactions to one's environment [68,69]. Incomplete or distorted emotional processing, in a sense, deprives individuals of data that is important to effective problem-solving. Poor understanding of the emotional domain also may result in unresolved negative affective states, and a prolongation of the physiological arousal that accompanies negative affect. Clinicians often report that the affect of somatizers seems incongruent with eliciting circumstances, being either dispropor‐ tionately flat or exaggerated. Both clinical impressions and the research literature suggest that somatizers fail to integrate and/or express fully their cognitive and affective responses to their environment. Using standard CBT to challenge cognitions that are disconnected from affective experiences seems misguided and unproductive. Thus, we have aimed to design a treatment that helps patients access, process, and accept their implicit cognitive and affective responses.

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 181

The components of treatment are relaxation training, behavioral management, cognitive restructuring, emotion identification, emotion regulation, and interpersonal skills training. Given that somatization patients typically seek relief from their physical ailments, not from emotional distress, they begin treatment more willing to learn behavioral skills than to explore emotional issues. The first sessions are skill-focused (i.e., training patients in relaxation and behavioral management). These initial sessions are designed to provide reductions in discom‐ fort, to introduce patients to the potential benefits of psychotherapy, and to establish a therapeutic alliance in a fashion that is consistent with patients' tastes, proclivities, and expectations. The second phase of treatment is a cognitive-emotional elicitation/regulation module intended to enhance patients' understanding of their thoughts and feelings so that they can interact more effectively with their environments. The third phase of treatment aims

The individual treatment begins with training in relaxation [73,74]. Emphasis is placed on incorporating relaxation into daily life, before and during stressful situations, and in response to feelings of physical discomfort. Relaxation serves a number of functions in the treatment of somatization. It may interrupt the muscle tension-pain cycle found in chronic pain patients [75]. It may reduce generalized physiological arousal or physiological reactivity [76]. Finally, cognitive benefits may result from patients' observations that they are not completely helpless

Once patients begin using one form of relaxation, training in behavioral management begins. This module of treatment aims to increase gradually patients' vocational, social, and self-care

to enhance interpersonal functioning and to confront and alter the "sick role."

victims of their symptoms, but instead have some control over them [76].

**6. Components of ACBT**

How, why, what aspects of CBT and ACBT works is unknown. We have very little data on the mechanisms by which efficacious psychosocial treatments may have their impact upon somatization. These approaches are multi-faceted and have not been disassembled into discrete components and those constituents systematically assessed. Nevertheless, CBT and ACBT are likely the treatments of choice by default in that no other intervention has demon‐ strated efficacy.

### **5. Rationale for an emotionally-focused CBT**

In our treatment for somatization we have made systematic and explicit an emphasis on emotional exploration, differentiation, and expression. This therapeutic activity has long been a staple of humanistic and psychoanalytic therapies and is coming to be emphasized by newer approaches that grow out of the cognitive-behavioral tradition. Traditional cognitive ap‐ proaches were based on a cognitive-appraisal theory of emotion [61,62] in which dysfunctional cognitions were thought to generate aversive affects. Although this view was modified to be more bidirectional and causally reciprocal by Teasdale [37], much CBT has been directed to the reduction of aversive affect, largely through the modification of cognition that was assumed to be the source. Some approaches that have developed within the CBT framework have begun to change this emphasis upon active control of emotion. Clinical work by such investigators as Marsha Linehan and Stephen Hayes has placed emphasis on experiencing, tolerating, and accepting unpleasant emotion, rather than seeking its elimination [63,64]. Recent formulations of generalized anxiety disorder (GAD) suggest that the function of this disorder's primary symptom, i.e., worry, may be to avoid, control, or attenuate emotional experience [65,66]. The authors of these recent formulations of GAD also advocate experiential and acceptance approaches as a means of reducing worry. Samoilov and Goldfried's critique of standard CBT approaches suggests more emphasis upon the elicitation of affect in therapy sessions may produce more effective treatment [67]. The arguments of the revisionist theorists cited above frequently draw from basic work in cognitive neuroscience, work that suggests there are complex, manifold, and partially independent levels of cognitive and affective storage and processing [68,69]. These "experiential" cognitive-behavioral treatments combine training aimed at either emotional exploration or emotional regulation. In an analysis of the perennial tensions between these two valid goals of therapy, Westen describes the broad and difficult therapeutic dilemmas relating the circumstances under which therapy should attempt to assist patients in accessing and exploring affective states or, alternatively, in eliminating those states [70]. He argues that traditional CBT approaches have erred in the direction of attempts to control emotions and failed to address adequately the implicit, tacit, irrational, nonverbal, and emotional aspects of existence.

Experimental research and clinical experience with somatization patients suggest these patients may be particularly well-suited to an emotionally-focused CBT. Investigators seeking to identify cognitive and affective characteristics of somatizing patients have found these patients to experience high rates of negative affect and to be less aware of and less able to describe thoughts and feelings than are other psychiatric patients [27-29]. Other authorities have discussed the "hysterical" emotional styles of these patients [71,72]. Our own impression is that whereas some somatizers manifest attenuated emotional processing and obliviousness to affect, others seem to have exaggerated emotional reactions. Some patients display each style, at different times. Contemporary theory in cognitive neuroscience suggests that emo‐ tional processing provides an important source of information about one's reactions to one's environment [68,69]. Incomplete or distorted emotional processing, in a sense, deprives individuals of data that is important to effective problem-solving. Poor understanding of the emotional domain also may result in unresolved negative affective states, and a prolongation of the physiological arousal that accompanies negative affect. Clinicians often report that the affect of somatizers seems incongruent with eliciting circumstances, being either dispropor‐ tionately flat or exaggerated. Both clinical impressions and the research literature suggest that somatizers fail to integrate and/or express fully their cognitive and affective responses to their environment. Using standard CBT to challenge cognitions that are disconnected from affective experiences seems misguided and unproductive. Thus, we have aimed to design a treatment that helps patients access, process, and accept their implicit cognitive and affective responses.

### **6. Components of ACBT**

examine the effectiveness of true collaboration of cognitive behavioral therapist and primary

How, why, what aspects of CBT and ACBT works is unknown. We have very little data on the mechanisms by which efficacious psychosocial treatments may have their impact upon somatization. These approaches are multi-faceted and have not been disassembled into discrete components and those constituents systematically assessed. Nevertheless, CBT and ACBT are likely the treatments of choice by default in that no other intervention has demon‐

In our treatment for somatization we have made systematic and explicit an emphasis on emotional exploration, differentiation, and expression. This therapeutic activity has long been a staple of humanistic and psychoanalytic therapies and is coming to be emphasized by newer approaches that grow out of the cognitive-behavioral tradition. Traditional cognitive ap‐ proaches were based on a cognitive-appraisal theory of emotion [61,62] in which dysfunctional cognitions were thought to generate aversive affects. Although this view was modified to be more bidirectional and causally reciprocal by Teasdale [37], much CBT has been directed to the reduction of aversive affect, largely through the modification of cognition that was assumed to be the source. Some approaches that have developed within the CBT framework have begun to change this emphasis upon active control of emotion. Clinical work by such investigators as Marsha Linehan and Stephen Hayes has placed emphasis on experiencing, tolerating, and accepting unpleasant emotion, rather than seeking its elimination [63,64]. Recent formulations of generalized anxiety disorder (GAD) suggest that the function of this disorder's primary symptom, i.e., worry, may be to avoid, control, or attenuate emotional experience [65,66]. The authors of these recent formulations of GAD also advocate experiential and acceptance approaches as a means of reducing worry. Samoilov and Goldfried's critique of standard CBT approaches suggests more emphasis upon the elicitation of affect in therapy sessions may produce more effective treatment [67]. The arguments of the revisionist theorists cited above frequently draw from basic work in cognitive neuroscience, work that suggests there are complex, manifold, and partially independent levels of cognitive and affective storage and processing [68,69]. These "experiential" cognitive-behavioral treatments combine training aimed at either emotional exploration or emotional regulation. In an analysis of the perennial tensions between these two valid goals of therapy, Westen describes the broad and difficult therapeutic dilemmas relating the circumstances under which therapy should attempt to assist patients in accessing and exploring affective states or, alternatively, in eliminating those states [70]. He argues that traditional CBT approaches have erred in the direction of attempts to control emotions and failed to address adequately the implicit, tacit, irrational,

Experimental research and clinical experience with somatization patients suggest these patients may be particularly well-suited to an emotionally-focused CBT. Investigators seeking

care clinician and integration of their services.

180 Mental Disorders - Theoretical and Empirical Perspectives

**5. Rationale for an emotionally-focused CBT**

nonverbal, and emotional aspects of existence.

strated efficacy.

The components of treatment are relaxation training, behavioral management, cognitive restructuring, emotion identification, emotion regulation, and interpersonal skills training. Given that somatization patients typically seek relief from their physical ailments, not from emotional distress, they begin treatment more willing to learn behavioral skills than to explore emotional issues. The first sessions are skill-focused (i.e., training patients in relaxation and behavioral management). These initial sessions are designed to provide reductions in discom‐ fort, to introduce patients to the potential benefits of psychotherapy, and to establish a therapeutic alliance in a fashion that is consistent with patients' tastes, proclivities, and expectations. The second phase of treatment is a cognitive-emotional elicitation/regulation module intended to enhance patients' understanding of their thoughts and feelings so that they can interact more effectively with their environments. The third phase of treatment aims to enhance interpersonal functioning and to confront and alter the "sick role."

The individual treatment begins with training in relaxation [73,74]. Emphasis is placed on incorporating relaxation into daily life, before and during stressful situations, and in response to feelings of physical discomfort. Relaxation serves a number of functions in the treatment of somatization. It may interrupt the muscle tension-pain cycle found in chronic pain patients [75]. It may reduce generalized physiological arousal or physiological reactivity [76]. Finally, cognitive benefits may result from patients' observations that they are not completely helpless victims of their symptoms, but instead have some control over them [76].

Once patients begin using one form of relaxation, training in behavioral management begins. This module of treatment aims to increase gradually patients' vocational, social, and self-care activities and to improve patients' mood and physical robustness. Also, sleep hygiene and stimulus control techniques are taught, as needed. The acquisition of these skills may also contribute to each patient's sense of self-efficacy in various areas and reduce feelings of powerlessness.

toms and about the impact those symptoms have upon their lives. Our questions about the particular nature of the symptoms, such as the types of pain (e.g., stabbing, pounding, burning, aching) and the situations in which symptoms typically occur, provide therapists with important information while concurrently validating patients' discomfort. Patients' beliefs about their physical symptoms and past coping techniques are also explored. Throughout this discussion and throughout the entire treatment, the therapist strives to acknowledge the physical symptoms and the distress associated with them. The therapist's efforts to validate the patient's discomfort and distress are critical to the development of therapeutic rapport. Because patients presenting with somatization symptoms are so accustomed to being dis‐ counted or dismissed by their healthcare providers, patients often become more willing to

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 183

After communicating a considered appreciation of the patient's difficulties, the therapist describes the treatment's rationale. A biopsychosocial model of physical symptoms is pro‐ posed. Here, the therapist's stance is empathic and non-confrontational. For patients who attribute their symptoms to an unknown biological mechanism or to toxic aspects of the physical environment, the therapist suggests that even if symptoms are caused by some organic pathology or by environmental agents, stress is likely to exacerbate them. In this way, the therapist aims to expand and to create variations in patients' explanations of their symp‐ toms, but is careful not to contradict patients' beliefs directly. Faulty beliefs about symptoms are more effectively challenged in future sessions after some trust and credibility have been

The treatment is described as stress management. The rationale presented is that because stress is likely to aggravate physical symptoms, the reduction of stress is likely to alleviate physical discomfort. Many patients are open to this idea and, indeed, some already believe that stress might have a physical impact upon their bodily sensations or indeed may have played a role in their underlying but unknown pathology. Most somatizing patients, however, would not accept the notion that their physical symptoms are entirely a "direct" product of stress. Therefore, it is important that therapists clarify that stress is only one factor contributing to patients' physical discomfort. The avowed aim of this treatment is, by limiting the adverse influence of stress, to give patients control over the aspects of their illness that can be controlled. Virtually all patients diagnosed with somatization syndromes have had extensive, unsatisfy‐ ing, and futile encounters with the healthcare system. Typically, our intervention is the latest in a long line of treatments, all of which have been failures. Given that their expectations are low, our patients must be motivated to come to therapy, despite minimal initial hope of success. Our patients tell us that what keeps them coming back is the opportunity to be treated by someone who cares about them and who makes a respectful effort to understand what their

In ACBT we place a great emphasis on psychotherapy as a caring encounter. We emphasize this to a greater degree than do many expositions of cognitive behavior therapy, a treatment that usually is associated with a didactic therapist-patient relationship, absent the emotional intensity of older more traditional forms of psychotherapy, such as psychoanalysis or clientcentered therapy. While it is true that in ACBT the therapist functions as a teacher and a trainer,

engage in treatment after they feel understood by the therapist.

established.

lives are like.

The cognitive-emotional elicitation/regulation module aims to help patients differentiate and understand their thoughts and feelings so that they can interact more effectively with their environments. The atmosphere of these sessions is more psychotherapeutic and less psycho‐ educational than that of the earlier sessions. Cognitive and emotion-focused strategies [77,78] in this module are integrated and individualized using case-based formulations [79]. Patients begin by monitoring their thoughts and emotions associated with changes in their physical symptoms. Experiential techniques, such as focusing [80] and techniques from Gestalt therapy [81], are used to assist patients in attending to, identifying, labeling, accepting, and expressing their thoughts and emotions. In our experience, somatization patients typically are disinclined to focus intensively on their emotional experiences. However, these patients are willing to explore emotions co-occurring with their physical symptoms and to try to make sense of those emotions by examining associated thoughts and behaviors. Once a patient's unique patterns of cognitive and emotional tendencies are identified, a semi-standardized, case-based formu‐ lation is used to guide the treatment. Emotional elicitation may be emphasized to help assimilate previously disowned or disavowed cognitive and/or emotional experiences. For example, if it is agreed that the patient inhibits feelings anger, portions of treatment sessions and homework may be devoted to facilitating the introspection, identification, labeling, and, perhaps, the expression of anger. Alternatively, emotional regulation strategies, including relaxation, distraction, cognitive restructuring, may be implemented for dysfunctional, destructive, exaggerated, or uncontrollable emotions. Determining which emotions, for a given individual in a given situation, need to be sought or amplified and which need to be examined through the lens of associated cognition or attenuated is a task that is central to the integration of cognitive and emotion-focused methods.

Cognitive interventions are based upon cognitive treatment programs for stress management [82] and pain management [83]. Cognitive errors characteristic of this population, such as thinking catastrophically about somatic symptoms, are addressed with cognitive restructuring techniques. Distraction is taught in order to reduce excessive attention paid to their physical sensations. Also, patients explore the function that the "sick role" plays in their social world. Specifically, they examine whether they derive secondary gains from their physical symptoms and disability. Treatment helps patients develop alternative strategies for attaining those gains derived from the sick role.

### **7. Therapeutic techniques**

The therapeutic posture we assume with patients and the rationale for treatment that we present to them are among the most important elements of our therapy. Our attitude toward patients is empathic and interested. We begin by asking patients about their physical symp‐ toms and about the impact those symptoms have upon their lives. Our questions about the particular nature of the symptoms, such as the types of pain (e.g., stabbing, pounding, burning, aching) and the situations in which symptoms typically occur, provide therapists with important information while concurrently validating patients' discomfort. Patients' beliefs about their physical symptoms and past coping techniques are also explored. Throughout this discussion and throughout the entire treatment, the therapist strives to acknowledge the physical symptoms and the distress associated with them. The therapist's efforts to validate the patient's discomfort and distress are critical to the development of therapeutic rapport. Because patients presenting with somatization symptoms are so accustomed to being dis‐ counted or dismissed by their healthcare providers, patients often become more willing to engage in treatment after they feel understood by the therapist.

activities and to improve patients' mood and physical robustness. Also, sleep hygiene and stimulus control techniques are taught, as needed. The acquisition of these skills may also contribute to each patient's sense of self-efficacy in various areas and reduce feelings of

The cognitive-emotional elicitation/regulation module aims to help patients differentiate and understand their thoughts and feelings so that they can interact more effectively with their environments. The atmosphere of these sessions is more psychotherapeutic and less psycho‐ educational than that of the earlier sessions. Cognitive and emotion-focused strategies [77,78] in this module are integrated and individualized using case-based formulations [79]. Patients begin by monitoring their thoughts and emotions associated with changes in their physical symptoms. Experiential techniques, such as focusing [80] and techniques from Gestalt therapy [81], are used to assist patients in attending to, identifying, labeling, accepting, and expressing their thoughts and emotions. In our experience, somatization patients typically are disinclined to focus intensively on their emotional experiences. However, these patients are willing to explore emotions co-occurring with their physical symptoms and to try to make sense of those emotions by examining associated thoughts and behaviors. Once a patient's unique patterns of cognitive and emotional tendencies are identified, a semi-standardized, case-based formu‐ lation is used to guide the treatment. Emotional elicitation may be emphasized to help assimilate previously disowned or disavowed cognitive and/or emotional experiences. For example, if it is agreed that the patient inhibits feelings anger, portions of treatment sessions and homework may be devoted to facilitating the introspection, identification, labeling, and, perhaps, the expression of anger. Alternatively, emotional regulation strategies, including relaxation, distraction, cognitive restructuring, may be implemented for dysfunctional, destructive, exaggerated, or uncontrollable emotions. Determining which emotions, for a given individual in a given situation, need to be sought or amplified and which need to be examined through the lens of associated cognition or attenuated is a task that is central to the

Cognitive interventions are based upon cognitive treatment programs for stress management [82] and pain management [83]. Cognitive errors characteristic of this population, such as thinking catastrophically about somatic symptoms, are addressed with cognitive restructuring techniques. Distraction is taught in order to reduce excessive attention paid to their physical sensations. Also, patients explore the function that the "sick role" plays in their social world. Specifically, they examine whether they derive secondary gains from their physical symptoms and disability. Treatment helps patients develop alternative strategies for attaining those gains

The therapeutic posture we assume with patients and the rationale for treatment that we present to them are among the most important elements of our therapy. Our attitude toward patients is empathic and interested. We begin by asking patients about their physical symp‐

integration of cognitive and emotion-focused methods.

derived from the sick role.

**7. Therapeutic techniques**

powerlessness.

182 Mental Disorders - Theoretical and Empirical Perspectives

After communicating a considered appreciation of the patient's difficulties, the therapist describes the treatment's rationale. A biopsychosocial model of physical symptoms is pro‐ posed. Here, the therapist's stance is empathic and non-confrontational. For patients who attribute their symptoms to an unknown biological mechanism or to toxic aspects of the physical environment, the therapist suggests that even if symptoms are caused by some organic pathology or by environmental agents, stress is likely to exacerbate them. In this way, the therapist aims to expand and to create variations in patients' explanations of their symp‐ toms, but is careful not to contradict patients' beliefs directly. Faulty beliefs about symptoms are more effectively challenged in future sessions after some trust and credibility have been established.

The treatment is described as stress management. The rationale presented is that because stress is likely to aggravate physical symptoms, the reduction of stress is likely to alleviate physical discomfort. Many patients are open to this idea and, indeed, some already believe that stress might have a physical impact upon their bodily sensations or indeed may have played a role in their underlying but unknown pathology. Most somatizing patients, however, would not accept the notion that their physical symptoms are entirely a "direct" product of stress. Therefore, it is important that therapists clarify that stress is only one factor contributing to patients' physical discomfort. The avowed aim of this treatment is, by limiting the adverse influence of stress, to give patients control over the aspects of their illness that can be controlled.

Virtually all patients diagnosed with somatization syndromes have had extensive, unsatisfy‐ ing, and futile encounters with the healthcare system. Typically, our intervention is the latest in a long line of treatments, all of which have been failures. Given that their expectations are low, our patients must be motivated to come to therapy, despite minimal initial hope of success. Our patients tell us that what keeps them coming back is the opportunity to be treated by someone who cares about them and who makes a respectful effort to understand what their lives are like.

In ACBT we place a great emphasis on psychotherapy as a caring encounter. We emphasize this to a greater degree than do many expositions of cognitive behavior therapy, a treatment that usually is associated with a didactic therapist-patient relationship, absent the emotional intensity of older more traditional forms of psychotherapy, such as psychoanalysis or clientcentered therapy. While it is true that in ACBT the therapist functions as a teacher and a trainer, she also is a confidant and a helper who must earn the patient's trust through being truthful, caring, and empathic. The kind of caring encounter that is based on genuine and sincerely felt compassion is essential to being effective with the patients we see. They have, in many cases, not been treated with kindness nor with courtesy. In the areas of civility and sympathy, our therapy often proves to be a corrective emotional experience. Caring and empathy are not, in themselves, sufficient to produce change in our patients, but they can be important elements in a restored sense of confidence in the healthcare system and in the resolution to attempt to cope with what can be great discomfort and disability.

with patients' physical capacities, so that exercise may eventually be reinforced by inherent natural contingencies. Overall, the acquisition of a broader repertory of activities also may serve to enhance each patient's self-efficacy in multiple areas and reduce feelings of infirmity

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 185

Activity pacing is an important topic to address when discussing the initiation of a new activity. Our clinical experience and some research suggest that some, if not many, somatization patients have perfectionistic tendencies driving them to over-achieve [84,85]. Our sense is that many of these patients may have difficulty moderating their activity levels; they over-function at times and under-function at other times. Of course, by the time they reach a psychothera‐ pist's office, they are under-functioning in important areas of their lives. Nevertheless, once they have been convinced to undertake an activity, they may be inclined to "overdo" it. Given the possibility that somatization patients may over-function or strive for perfection in therapy, the therapist emphasizes the importance of making small changes in a specific behavior at first and subsequently instituting gradual increases in that activity over the course of therapy. Other ways in which activity pacing is incorporated into therapy is by persuading patients to take

To increase the likelihood that behavioral changes become a permanent part of patients' lives, they are discussed throughout treatment. The therapist monitors all changed behaviors every

Many patients with somatization syndromes report significant sleep disturbance [86]. Failure to receive adequate restorative sleep is a contributory factor in exacerbating many psychiatric disorders. In somatizers, almost invariably, sleep loss is correlated with a worsening of symptoms. We now believe that treating insomnia early and aggressively is a key to successful

Many of our patients, especially those not working outside their homes, engage in problematic sleep practices that may increase the likelihood of insomnia, such as taking naps during the day, keeping erratic sleep schedules, and watching television in bed. To combat poor sleep habits, we provide patients with brief psychoeducational training in sleep hygiene and

The cognitive-emotional elicitation/regulation components of treatment aim to help patients differentiate and understand their thoughts and feelings so that they can interact more effectively with their environments. The atmosphere of sessions devoted to this enterprise is more psychotherapeutic and less psychoeducational than that of the earlier sessions that are

Patients begin this phase of treatment by monitoring their thoughts and emotions that are associated with changes in their physical symptoms. Experiential techniques, such as focusing [80] and techniques from Gestalt therapy [81], are used to assist patients in attending to, identifying, labeling, accepting, and expressing their thoughts and emotions. In our experi‐ ence, somatization patients typically are disinclined to focus intensively on their emotional

focused upon relaxation training and making behavioral changes.

and powerlessness.

week of treatment.

treatment of somatization.

stimulus control techniques [87].

**7.3. Identifying thoughts and feelings**

frequent breaks in the midst of their daily routines.

### **7.1. Relaxation**

We typically teach diaphragmatic breathing for the first month of treatment and an abbreviated progressive muscle relaxation (PMR) for the second month of treatment. Diaphragmatic breathing can be used in concert with PMR. We subscribe to the view that relaxation training is most effective when it enables the trainee to learn how to relax on any given occasion and throughout the day, as opposed to extended sessions occurring once or twice per day during scheduled times when an especially deep state of lowered arousal is achieved.

The therapist introduces diaphragmatic breathing and explains that the long-term goal is for the patient to breathe abdominally as much as possible. However, regular abdominal breathing takes time to establish if it is a departure from the patient's typical practice. Over the course of treatment, the patient is asked to practice breathing abdominally between sessions and to report back on her progress. Eventually, breathing abdominally may coincide with reductions in tension and discomfort, though the patient should be warned not to be disappointed if she initially experiences little significant relief.

The crucial challenge in relaxation training is helping patients use the techniques on a regular basis. The considerable amount of therapy time used to describe, practice, and effectively implement relaxation techniques indicates the importance we place on using them. Even though training in relaxation is often completed by the eighth week of treatment, we continue to inquire into patients' use of relaxation throughout our work with them. Some patients learn to use both abbreviated PMR and abdominal breathing, either in combination or separately. Others have a strong preference for one method or the other. We attempt to train patients in two forms of relaxation and to allow the patient to decide ultimately which to employ. At this point the research literature cannot demonstrate that any form of systematic relaxation will be superior to others for a given individual [76]. What is clear, however, is that relaxation is beneficial only if it is utilized.

### **7.2. Behavioral management**

Behavioral methods are largely based upon the principles of classical and operant condition‐ ing. Existing pathogenic contingencies of reinforcement are replaced with salutary ones. For example, patients learn to connect with friends and family by engaging with them in pleas‐ urable activities instead of interacting with them through activities focused on the patients' physical discomfort. Exercise assignments are designed to be pleasurable and commensurate with patients' physical capacities, so that exercise may eventually be reinforced by inherent natural contingencies. Overall, the acquisition of a broader repertory of activities also may serve to enhance each patient's self-efficacy in multiple areas and reduce feelings of infirmity and powerlessness.

Activity pacing is an important topic to address when discussing the initiation of a new activity. Our clinical experience and some research suggest that some, if not many, somatization patients have perfectionistic tendencies driving them to over-achieve [84,85]. Our sense is that many of these patients may have difficulty moderating their activity levels; they over-function at times and under-function at other times. Of course, by the time they reach a psychothera‐ pist's office, they are under-functioning in important areas of their lives. Nevertheless, once they have been convinced to undertake an activity, they may be inclined to "overdo" it. Given the possibility that somatization patients may over-function or strive for perfection in therapy, the therapist emphasizes the importance of making small changes in a specific behavior at first and subsequently instituting gradual increases in that activity over the course of therapy. Other ways in which activity pacing is incorporated into therapy is by persuading patients to take frequent breaks in the midst of their daily routines.

To increase the likelihood that behavioral changes become a permanent part of patients' lives, they are discussed throughout treatment. The therapist monitors all changed behaviors every week of treatment.

Many patients with somatization syndromes report significant sleep disturbance [86]. Failure to receive adequate restorative sleep is a contributory factor in exacerbating many psychiatric disorders. In somatizers, almost invariably, sleep loss is correlated with a worsening of symptoms. We now believe that treating insomnia early and aggressively is a key to successful treatment of somatization.

Many of our patients, especially those not working outside their homes, engage in problematic sleep practices that may increase the likelihood of insomnia, such as taking naps during the day, keeping erratic sleep schedules, and watching television in bed. To combat poor sleep habits, we provide patients with brief psychoeducational training in sleep hygiene and stimulus control techniques [87].

### **7.3. Identifying thoughts and feelings**

she also is a confidant and a helper who must earn the patient's trust through being truthful, caring, and empathic. The kind of caring encounter that is based on genuine and sincerely felt compassion is essential to being effective with the patients we see. They have, in many cases, not been treated with kindness nor with courtesy. In the areas of civility and sympathy, our therapy often proves to be a corrective emotional experience. Caring and empathy are not, in themselves, sufficient to produce change in our patients, but they can be important elements in a restored sense of confidence in the healthcare system and in the resolution to attempt to

We typically teach diaphragmatic breathing for the first month of treatment and an abbreviated progressive muscle relaxation (PMR) for the second month of treatment. Diaphragmatic breathing can be used in concert with PMR. We subscribe to the view that relaxation training is most effective when it enables the trainee to learn how to relax on any given occasion and throughout the day, as opposed to extended sessions occurring once or twice per day during

The therapist introduces diaphragmatic breathing and explains that the long-term goal is for the patient to breathe abdominally as much as possible. However, regular abdominal breathing takes time to establish if it is a departure from the patient's typical practice. Over the course of treatment, the patient is asked to practice breathing abdominally between sessions and to report back on her progress. Eventually, breathing abdominally may coincide with reductions in tension and discomfort, though the patient should be warned not to be disappointed if she

The crucial challenge in relaxation training is helping patients use the techniques on a regular basis. The considerable amount of therapy time used to describe, practice, and effectively implement relaxation techniques indicates the importance we place on using them. Even though training in relaxation is often completed by the eighth week of treatment, we continue to inquire into patients' use of relaxation throughout our work with them. Some patients learn to use both abbreviated PMR and abdominal breathing, either in combination or separately. Others have a strong preference for one method or the other. We attempt to train patients in two forms of relaxation and to allow the patient to decide ultimately which to employ. At this point the research literature cannot demonstrate that any form of systematic relaxation will be superior to others for a given individual [76]. What is clear, however, is that relaxation is

Behavioral methods are largely based upon the principles of classical and operant condition‐ ing. Existing pathogenic contingencies of reinforcement are replaced with salutary ones. For example, patients learn to connect with friends and family by engaging with them in pleas‐ urable activities instead of interacting with them through activities focused on the patients' physical discomfort. Exercise assignments are designed to be pleasurable and commensurate

scheduled times when an especially deep state of lowered arousal is achieved.

cope with what can be great discomfort and disability.

184 Mental Disorders - Theoretical and Empirical Perspectives

initially experiences little significant relief.

beneficial only if it is utilized.

**7.2. Behavioral management**

**7.1. Relaxation**

The cognitive-emotional elicitation/regulation components of treatment aim to help patients differentiate and understand their thoughts and feelings so that they can interact more effectively with their environments. The atmosphere of sessions devoted to this enterprise is more psychotherapeutic and less psychoeducational than that of the earlier sessions that are focused upon relaxation training and making behavioral changes.

Patients begin this phase of treatment by monitoring their thoughts and emotions that are associated with changes in their physical symptoms. Experiential techniques, such as focusing [80] and techniques from Gestalt therapy [81], are used to assist patients in attending to, identifying, labeling, accepting, and expressing their thoughts and emotions. In our experi‐ ence, somatization patients typically are disinclined to focus intensively on their emotional experiences. However, these patients often are willing to explore emotions co-occurring with their physical symptoms and to try to make sense of those emotions by examining the associated thoughts and behaviors.

therapy via homework assignments that call upon the patient to identify and record emotions,

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 187

An important component of treatment is to help patients examine their cognitive tenden‐ cies. After reviewing a few weeks of a patient's symptom monitoring forms, the therapist will have a sense of the patient's typical dysfunctional thinking patterns. Typical cogni‐ tive errors that we have observed include perfectionistic thoughts, catastrophic thoughts (about physical symptoms as well as other life events), overestimating the possibility of negative outcomes, "should" statements, and dichotomous thinking. Our sense is that at the core of these errors is a global negative perception of self as being inadequate or un‐ lovable. Although many patients may not acknowledge seeing themselves as inadequate or unlovable, especially a brief episode of treatment, thoughts about being weak, vulner‐ able, undesirable, unattractive, or helpless may not be far from the surface when the "meaning" of a thought is explored. Once these kinds of dysfunctional beliefs are identi‐

In hopes of interrupting the dysfunctional pattern of physical symptoms prompting physician visits that fail to alleviate or even exacerbate those symptoms, the therapist helps the patient learn to reconsider the thoughts fueling illness behavior. Our patients often make comments like, "there must be something wrong with me that my doctor hasn't found." If such a belief is sound, the rational response is to seek additional diagnostic procedures. However, such beliefs may be assailable. Patients are encouraged to look at the evidence either supporting or undermining that belief. Questions like, "What makes you think there is something medically wrong with you?" or "What evidence is there that the doctor has missed something?" are followed by "What evidence is there that you may not have a serious medical problem?" Also, patients are questioned about the advantages and disadvantages of having another diagnostic procedure. They are asked what would convince them that they are not suffering from the illness they fear. The grounds for the falsification of beliefs are explored extensively to demonstrate that one can never be 100% certain of perfect health. In addition to challenging patients' beliefs associated with illness behavior, the therapist constructs behavioral experi‐ ments in which patients test the consequences of avoiding (or, at least, delaying) physician visits. Symptom monitoring forms are used to assess the impact of modifying this aspect of illness behavior. If patients can delay a physician visit long enough, the somatization symptom

that initially prompted the intent to seek medical treatment may subside.

patient ask directly for more attention and affection.

The goal of the sick role discussion is to provide patients with some insight into any secondary gain they might derive while experiencing pain or discomfort and to examine the possibility that illness behavior has become habitual. Having identified the secondary gain, the therapist and patient collaborate to find alternative methods for attaining the sick role's benefits. For example, if the patient's spouse is especially nurturing when the patient is in pain, we help the

as well as associated physical symptoms and thoughts.

fied, we employ cognitive restructuring techniques [88].

**7.4. Cognitive restructuring**

**7.5. Addressing illness behavior**

Symptom monitoring forms are introduced to help patients focus their attention on thoughts and feelings between sessions. These forms are analogous to dysfunctional thought records used with depressed patients [88]. Our symptom monitoring forms require patients to describe two specific moments each day: 1) when their physical symptoms are relatively severe and 2) when their physical symptoms are relatively less severe and they are experiencing greater relative comfort. Because the goal here is to increase patients' awareness rather than to assess symptom severity, it is not critical that the patient write about "the most uncomfortable" or "the least uncomfortable" period of the day. We aim for a record of a representative "physically uncomfortable" and "physically less uncomfortable" episodes. Ideally, these entries will be made as proximate to the time of occurrence as possible at a time each day when patients experienced noteworthy discomfort or the absence of discomfort. On days without significant variation in physical discomfort, patients' instructions are to choose, retrospectively, episodes of relative comfort and discomfort. At the moment of recording, patients note the time of day, the physical symptoms experienced, the environmental circumstances, and thoughts and emotions concurrent with the physical symptoms. The monitoring forms can be used to detect patterns in symptoms and in the relationships among symptoms, thoughts, and emotions.

An initial task is to teach patients to distinguish between physical sensations and emotions as well as to differentiate thoughts from emotions. For example, if a patient says that her physical sensations included anxiety, the therapist might reply, "I would consider anxiety an emotion, not a physical sensation. So, let's put that in the emotion column. But, sometimes people have physical sensations that accompany anxiety. Did you feel anything in your body, any physical sensation, at that time that coincided with the anxiety?" Similarly, if a patient says that she felt stupid, the therapist should 1) label this experience as that of the evaluative cognition that "I am stupid," 2) distinguish cognition and emotion, and 3) question the patient about the emotion that coincided with that cognition. Also, emphasis is placed upon learning to differentiate among emotions. (Patients are asked to use specific emotion terms such as "sad," "worried," or "annoyed," instead of more nebulous emotion terms such as "stressed," "bad," or "upset.")

Many patients presenting with somatization struggle with the self-awareness activities because of difficulties in identifying and differentiating among their thoughts and feelings. Whatever the cause of this difficulty (e.g., alexithymia, repressive coping), our efforts focus on enhancing awareness and acceptance of thoughts and feelings. Many patients find that recognizing and expressing thoughts and/or feelings may be the most difficult component of treatment. Nevertheless, these initial skills must be mastered before cognitive restructuring techniques can be taught. Disputing cognitions is futile unless one can identify one's thoughts and feelings. The heightening of patients' self-awareness is facilitated by therapists' refraining from disputing cognitions until a thorough investigation of emotions and their companion cognitions has been conducted. We want patients to be able to experience and communicate emotions during a session. This work in session is extended to the patient's life outside of therapy via homework assignments that call upon the patient to identify and record emotions, as well as associated physical symptoms and thoughts.

### **7.4. Cognitive restructuring**

experiences. However, these patients often are willing to explore emotions co-occurring with their physical symptoms and to try to make sense of those emotions by examining the

Symptom monitoring forms are introduced to help patients focus their attention on thoughts and feelings between sessions. These forms are analogous to dysfunctional thought records used with depressed patients [88]. Our symptom monitoring forms require patients to describe two specific moments each day: 1) when their physical symptoms are relatively severe and 2) when their physical symptoms are relatively less severe and they are experiencing greater relative comfort. Because the goal here is to increase patients' awareness rather than to assess symptom severity, it is not critical that the patient write about "the most uncomfortable" or "the least uncomfortable" period of the day. We aim for a record of a representative "physically uncomfortable" and "physically less uncomfortable" episodes. Ideally, these entries will be made as proximate to the time of occurrence as possible at a time each day when patients experienced noteworthy discomfort or the absence of discomfort. On days without significant variation in physical discomfort, patients' instructions are to choose, retrospectively, episodes of relative comfort and discomfort. At the moment of recording, patients note the time of day, the physical symptoms experienced, the environmental circumstances, and thoughts and emotions concurrent with the physical symptoms. The monitoring forms can be used to detect patterns in symptoms and in the relationships among symptoms, thoughts, and emotions.

An initial task is to teach patients to distinguish between physical sensations and emotions as well as to differentiate thoughts from emotions. For example, if a patient says that her physical sensations included anxiety, the therapist might reply, "I would consider anxiety an emotion, not a physical sensation. So, let's put that in the emotion column. But, sometimes people have physical sensations that accompany anxiety. Did you feel anything in your body, any physical sensation, at that time that coincided with the anxiety?" Similarly, if a patient says that she felt stupid, the therapist should 1) label this experience as that of the evaluative cognition that "I am stupid," 2) distinguish cognition and emotion, and 3) question the patient about the emotion that coincided with that cognition. Also, emphasis is placed upon learning to differentiate among emotions. (Patients are asked to use specific emotion terms such as "sad," "worried," or "annoyed," instead of more nebulous emotion terms such as "stressed," "bad," or "upset.")

Many patients presenting with somatization struggle with the self-awareness activities because of difficulties in identifying and differentiating among their thoughts and feelings. Whatever the cause of this difficulty (e.g., alexithymia, repressive coping), our efforts focus on enhancing awareness and acceptance of thoughts and feelings. Many patients find that recognizing and expressing thoughts and/or feelings may be the most difficult component of treatment. Nevertheless, these initial skills must be mastered before cognitive restructuring techniques can be taught. Disputing cognitions is futile unless one can identify one's thoughts and feelings. The heightening of patients' self-awareness is facilitated by therapists' refraining from disputing cognitions until a thorough investigation of emotions and their companion cognitions has been conducted. We want patients to be able to experience and communicate emotions during a session. This work in session is extended to the patient's life outside of

associated thoughts and behaviors.

186 Mental Disorders - Theoretical and Empirical Perspectives

An important component of treatment is to help patients examine their cognitive tenden‐ cies. After reviewing a few weeks of a patient's symptom monitoring forms, the therapist will have a sense of the patient's typical dysfunctional thinking patterns. Typical cogni‐ tive errors that we have observed include perfectionistic thoughts, catastrophic thoughts (about physical symptoms as well as other life events), overestimating the possibility of negative outcomes, "should" statements, and dichotomous thinking. Our sense is that at the core of these errors is a global negative perception of self as being inadequate or un‐ lovable. Although many patients may not acknowledge seeing themselves as inadequate or unlovable, especially a brief episode of treatment, thoughts about being weak, vulner‐ able, undesirable, unattractive, or helpless may not be far from the surface when the "meaning" of a thought is explored. Once these kinds of dysfunctional beliefs are identi‐ fied, we employ cognitive restructuring techniques [88].

### **7.5. Addressing illness behavior**

In hopes of interrupting the dysfunctional pattern of physical symptoms prompting physician visits that fail to alleviate or even exacerbate those symptoms, the therapist helps the patient learn to reconsider the thoughts fueling illness behavior. Our patients often make comments like, "there must be something wrong with me that my doctor hasn't found." If such a belief is sound, the rational response is to seek additional diagnostic procedures. However, such beliefs may be assailable. Patients are encouraged to look at the evidence either supporting or undermining that belief. Questions like, "What makes you think there is something medically wrong with you?" or "What evidence is there that the doctor has missed something?" are followed by "What evidence is there that you may not have a serious medical problem?" Also, patients are questioned about the advantages and disadvantages of having another diagnostic procedure. They are asked what would convince them that they are not suffering from the illness they fear. The grounds for the falsification of beliefs are explored extensively to demonstrate that one can never be 100% certain of perfect health. In addition to challenging patients' beliefs associated with illness behavior, the therapist constructs behavioral experi‐ ments in which patients test the consequences of avoiding (or, at least, delaying) physician visits. Symptom monitoring forms are used to assess the impact of modifying this aspect of illness behavior. If patients can delay a physician visit long enough, the somatization symptom that initially prompted the intent to seek medical treatment may subside.

The goal of the sick role discussion is to provide patients with some insight into any secondary gain they might derive while experiencing pain or discomfort and to examine the possibility that illness behavior has become habitual. Having identified the secondary gain, the therapist and patient collaborate to find alternative methods for attaining the sick role's benefits. For example, if the patient's spouse is especially nurturing when the patient is in pain, we help the patient ask directly for more attention and affection.

Examining the sick role's benefits is a sensitive issue because family, friends, and physicians may have accused the patient of faking, imagining, or exaggerating his symptoms. Thus, the therapist is careful not to imply that the patient is choosing to experience his symptoms. The discussion will be fruitless if the patient becomes defensive. Because of the sensitivity of this topic, we typically defer its discussion until the third month of treatment.

tiveness and to provide few opportunities to hone skills of self-assertion, except perhaps in

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 189

If the patient acknowledges that the sick role has become "second nature" to him, we may borrow a technique of fixed-role therapy [90] and have our patient attempt to play the part of a "healthy person" in one or more activities. One method is to ask the patient to find a rolemodel who is not impaired and to imitate that person's behavior. Another is to have the patient ask the question, "What would a healthy person do in this situation?" and then to act out the answer. Occasionally, as much psychological research has shown, changes in attitudes and emotions will follow changes in behavior rather than preceding them. Expanding the range of the patient's behavior, before the patient feels "healthy enough," can be effective, if the approach is used judiciously. How much to push somatizers to extend themselves is a matter of clinical judgment. Good therapeutic decisions in this area tend to optimize treatment

At this point in treatment, the therapist will have assessed for deficits in the patient's asser‐ tiveness. Some patients effectively assert themselves and have their needs met in some, but not all, situations. Some patients can assert themselves only in regard to certain kinds of needs. Other patients can assert their needs when they are aware of them, but may not always be aware of what those needs might be. Other patients have pervasive, trait-like deficits in assertiveness across virtually all areas of their lives. In our experience, all somatization patients have difficulty expressing their thoughts and feelings assertively in, at least, some situations. The therapist begins by defining assertiveness and explaining the rationale for helping the patient act more assertively in some situations. We define assertiveness as an open and honest expression of one's thoughts and feelings that avoids blaming or attacking others. Much of ACBT treatment, up to this point, has provided the groundwork for becoming assertive. For example, the self-awareness exercises and symptom monitoring forms direct the patient to pay attention to her thoughts and feelings. Stage 1 of acting assertively involves identifying thoughts and feelings. Stage 2, valuing one's thoughts and feelings, is implicit in and fostered by some of the behavioral techniques. By taking time to relax and to engage in pleasurable activities, patients are, in effect, affirming the value and legitimacy of taking care of themselves. Before introducing stage 3 of assertiveness, patients may need additional work on stages 1 and 2. Specifically, patients might be asked to track their thoughts and feelings when interacting with others between therapy sessions. (At this point in treatment, unassertive individuals often can identify their thoughts and feelings when they are alone. Yet, they may have difficulty being self-aware while interacting with others, especially others who are accustomed to or expect them to be unassertive.) A homework assignment might be to ask, "What do I think and feel?" during various interactions with others. For patients who continue to have trouble valuing their thoughts and feelings, the therapist should use the technique from fixed-role therapy [89]. Patients are directed to role-play in the outside world, to behave as they would if they really did think their own feelings and needs were important. Through this device, assertive behavior, with a tone of conviction, can be practiced and its often successful results

interactions with healthcare providers.

outcomes.

**7.6. Assertiveness**

To avoid raising the patient's defenses initially, the discussion begins by focusing on the patient's perceptions of other people who have been ill, other people whom the patient knows or has known well. The therapist asks who, in the patient's family and social circle, had health problems during the patient's childhood (or during the patient's adulthood, if no one had health problems during the patient's childhood). In our clinical experience, as in Craig et al.'s research [89], many patients meeting criteria for a somatoform disorder report having observed illness during childhood in either a family member or a close friend. The patient is asked to describe the individual who was ill and to talk about the ways in which that person's life was affected by illness or physical discomfort. Specifically, the therapist asks about the sick person's missed opportunities and missed experiences and how others responded to the person. Next, the therapist inquires into "the silver lining" that being unhealthy may have had for the sick person. "Were there any benefits of being unhealthy for that individual?" If the patient believes there were no benefits, the therapist may ask specifically about each of the following possible benefits: receiving special attention or nurture, avoiding undesirable activities, avoiding arguments, gaining a special role in the family, or diminishing one's own expectations for oneself. Usually the patient will acknowledge that the ill individual experi‐ enced some benefits from his or her illness.

Having discussed another person's experiences with illness, the therapist shifts the discussion to the impact of illness upon the patient's life. The therapist begins with inquiries into the patient's experience of illness as a child: "How did others respond to you when you were sick or in pain as a child?" "Were you taken to the doctor or did you miss school when you were sick?" "Did you receive special attention or treatment when you were sick?" Afterwards, questions focus on the impact of illness during the patient's adult life: "In previous sessions we discussed the many disadvantages of your health problems these days, are there any advantages to being sick?"

Although almost all of our patients have acknowledged that some benefits accrue from "being sick," therapists often feel anxious during this discussion. It may seem likely that explicit discussion with the patient about the sick role will undermine the therapeutic relationship. But in our experience, no patient has withdrawn prematurely from treatment after discussing the sick role. Although the topic is a sensitive one, it can be productively examined.

Often the discussion of the sick role begins to provide a rationale for assertiveness training as it may reveal deficits in the patient's assertiveness. If the patient is deriving substantial attention or nurture through being sick, he also may be deficient in the ability to ask directly for attention and nurture. Patients who avoid undesirable activities by being sick may have difficulty setting limits on others. One advantage of the sick role is that people can be rewarded without having to ask directly for what they want. The sick role tends to undermine asser‐ tiveness and to provide few opportunities to hone skills of self-assertion, except perhaps in interactions with healthcare providers.

If the patient acknowledges that the sick role has become "second nature" to him, we may borrow a technique of fixed-role therapy [90] and have our patient attempt to play the part of a "healthy person" in one or more activities. One method is to ask the patient to find a rolemodel who is not impaired and to imitate that person's behavior. Another is to have the patient ask the question, "What would a healthy person do in this situation?" and then to act out the answer. Occasionally, as much psychological research has shown, changes in attitudes and emotions will follow changes in behavior rather than preceding them. Expanding the range of the patient's behavior, before the patient feels "healthy enough," can be effective, if the approach is used judiciously. How much to push somatizers to extend themselves is a matter of clinical judgment. Good therapeutic decisions in this area tend to optimize treatment outcomes.

### **7.6. Assertiveness**

Examining the sick role's benefits is a sensitive issue because family, friends, and physicians may have accused the patient of faking, imagining, or exaggerating his symptoms. Thus, the therapist is careful not to imply that the patient is choosing to experience his symptoms. The discussion will be fruitless if the patient becomes defensive. Because of the sensitivity of this

To avoid raising the patient's defenses initially, the discussion begins by focusing on the patient's perceptions of other people who have been ill, other people whom the patient knows or has known well. The therapist asks who, in the patient's family and social circle, had health problems during the patient's childhood (or during the patient's adulthood, if no one had health problems during the patient's childhood). In our clinical experience, as in Craig et al.'s research [89], many patients meeting criteria for a somatoform disorder report having observed illness during childhood in either a family member or a close friend. The patient is asked to describe the individual who was ill and to talk about the ways in which that person's life was affected by illness or physical discomfort. Specifically, the therapist asks about the sick person's missed opportunities and missed experiences and how others responded to the person. Next, the therapist inquires into "the silver lining" that being unhealthy may have had for the sick person. "Were there any benefits of being unhealthy for that individual?" If the patient believes there were no benefits, the therapist may ask specifically about each of the following possible benefits: receiving special attention or nurture, avoiding undesirable activities, avoiding arguments, gaining a special role in the family, or diminishing one's own expectations for oneself. Usually the patient will acknowledge that the ill individual experi‐

Having discussed another person's experiences with illness, the therapist shifts the discussion to the impact of illness upon the patient's life. The therapist begins with inquiries into the patient's experience of illness as a child: "How did others respond to you when you were sick or in pain as a child?" "Were you taken to the doctor or did you miss school when you were sick?" "Did you receive special attention or treatment when you were sick?" Afterwards, questions focus on the impact of illness during the patient's adult life: "In previous sessions we discussed the many disadvantages of your health problems these days, are there any

Although almost all of our patients have acknowledged that some benefits accrue from "being sick," therapists often feel anxious during this discussion. It may seem likely that explicit discussion with the patient about the sick role will undermine the therapeutic relationship. But in our experience, no patient has withdrawn prematurely from treatment after discussing

Often the discussion of the sick role begins to provide a rationale for assertiveness training as it may reveal deficits in the patient's assertiveness. If the patient is deriving substantial attention or nurture through being sick, he also may be deficient in the ability to ask directly for attention and nurture. Patients who avoid undesirable activities by being sick may have difficulty setting limits on others. One advantage of the sick role is that people can be rewarded without having to ask directly for what they want. The sick role tends to undermine asser‐

the sick role. Although the topic is a sensitive one, it can be productively examined.

topic, we typically defer its discussion until the third month of treatment.

enced some benefits from his or her illness.

188 Mental Disorders - Theoretical and Empirical Perspectives

advantages to being sick?"

At this point in treatment, the therapist will have assessed for deficits in the patient's asser‐ tiveness. Some patients effectively assert themselves and have their needs met in some, but not all, situations. Some patients can assert themselves only in regard to certain kinds of needs. Other patients can assert their needs when they are aware of them, but may not always be aware of what those needs might be. Other patients have pervasive, trait-like deficits in assertiveness across virtually all areas of their lives. In our experience, all somatization patients have difficulty expressing their thoughts and feelings assertively in, at least, some situations.

The therapist begins by defining assertiveness and explaining the rationale for helping the patient act more assertively in some situations. We define assertiveness as an open and honest expression of one's thoughts and feelings that avoids blaming or attacking others. Much of ACBT treatment, up to this point, has provided the groundwork for becoming assertive. For example, the self-awareness exercises and symptom monitoring forms direct the patient to pay attention to her thoughts and feelings. Stage 1 of acting assertively involves identifying thoughts and feelings. Stage 2, valuing one's thoughts and feelings, is implicit in and fostered by some of the behavioral techniques. By taking time to relax and to engage in pleasurable activities, patients are, in effect, affirming the value and legitimacy of taking care of themselves.

Before introducing stage 3 of assertiveness, patients may need additional work on stages 1 and 2. Specifically, patients might be asked to track their thoughts and feelings when interacting with others between therapy sessions. (At this point in treatment, unassertive individuals often can identify their thoughts and feelings when they are alone. Yet, they may have difficulty being self-aware while interacting with others, especially others who are accustomed to or expect them to be unassertive.) A homework assignment might be to ask, "What do I think and feel?" during various interactions with others. For patients who continue to have trouble valuing their thoughts and feelings, the therapist should use the technique from fixed-role therapy [89]. Patients are directed to role-play in the outside world, to behave as they would if they really did think their own feelings and needs were important. Through this device, assertive behavior, with a tone of conviction, can be practiced and its often successful results can be witnessed by the patient. Occasionally patients will adopt and assimilate features of this more assertive persona.

might, yet again, enjoy together. Afterwards, the couple and therapist collaborate to develop a plan for increasing pleasurable conjoint activities. Reengaging in these activities may increase satisfaction with the relationship as well as reduce the patient's focus upon her symptoms. A subsidiary aim of the conjoint sessions is to address the couple's communication about the patient's physical symptoms. Initially the therapist asks the couple to describe a few recent discussions about the patient's physical symptoms. Both members of the couple are asked to describe what each said about the symptoms and what each thought and felt at that time. Afterwards, the therapist summarizes and reflects upon the couple's communication about the patient's symptoms. Suggestions for alternative modes of interacting, that are less likely to

Somatic Symptom Disorder http://dx.doi.org/10.5772/52431 191

Somatic symptom disorder and related disorders are distressing, disabling, and costly disorders. Although the treatment of somatization and of somatic symptom disorder is in its infancy, there is sufficient evidence to believe CBT and ACBT have therapeutic value. Given the research conducted to date, we recommend CBT and ACBT as the treatments of choice for these disorders. A manualized 10-session version of our treatment [51] has been tested and found effective with patients diagnosed with very severe as well as more moderate levels of

[1] Gureje O, Simon GE. The natural history of somatization in primary care. Psychol

[2] Smith GR, Monson RA, Ray DC. Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med

[3] Katon W, Lin E, Von Korff M, Russo J, Lipscomb P, Bush T. Somatization: a spectrum

reinforce illness behavior, are provided.

Lesley A. Allen and Robert L. Woolfolk\*

Med 1999;29:669-676.

1986;146:69-72.

\*Address all correspondence to: woolfolk@princeton.edu

of severity. Am J Psychiatry 1991;148:34-40.

Department of Psychology, Princeton University, Princeton, NJ, USA

**8. Conclusions**

somatization [52, 53].

**Author details**

**References**

Stage 3 of assertiveness involves communicating one's thoughts, feelings, desires, and needs with "I statements". The therapist suggests the patient use the following statement as a model, "I feel \_\_\_\_\_\_\_\_\_\_\_, when you \_\_\_\_\_\_\_\_\_\_\_." An example of content in this form is, "I felt worried when you didn't call to tell me you'd be late coming home from work last night." By making such a statement, this individual is taking responsibility for her feelings as opposed to blaming others (e.g., "You're so selfish not to have called"). Also, the statement is indisput‐ able since it is an expression of the patient's emotional reaction. The result is that the person being spoken to is somewhat less likely to react defensively than if attacked or explicitly criticized; the person addressed also may be less likely to attempt to refute the assertion itself.

### **7.7. Sessions with spouse or significant other**

The goals of including the significant other (domestic partner spouse) in treatment are to obtain additional information about the patient, to gain the significant other's support for the treatment, and to alter behaviors of the significant other that may reinforce the patient's symptoms or illness behavior. We view this aspect of the treatment to be so valuable that, even when working within our 10-session treatment format, we ask the patient's significant other to join us for 1 to 3 of those 10 sessions.

We typically invite the significant other to participate in a conjoint session within the first month of treatment. The rationale for meeting together with the patient and significant other is to encourage an open dialogue. In our experience, the therapeutic relationship is not always strong enough to tolerate a therapist's meeting separately with a significant other, as some patients readily become suspicious that "behind my back" others are minimizing their degree of discomfort. And, although we would like to begin deriving the benefits of including the significant other in treatment as soon as possible, for logistical reasons we typically delay the first conjoint session until we have had some time to develop rapport with the patient. We find the third or forth session works well as an initial conjoint session.

The focus of the conjoint session(s) includes discussions about the rationale for a "stress management" treatment and about how such a treatment could be maximally helpful to the patient. The therapist asks the significant other to comment on the impact of stress upon the patient's physical symptoms. Also, the impact of the patient's physical symptoms on the patient's and significant other's lives is examined. Here we aim to elicit information and to suggest that the significant other's involvement in treatment may benefit both parties. Reducing the likelihood that the significant other will undermine the treatment is critical.

After clarifying the treatment's rationale, the therapist attempts to determine whether the significant relationship has been impaired by the patient's illness. Somatizers' tendencies to withdraw from activities may not only diminish pleasure in their own lives, but also in their significant others' lives. When a patient foregoes couple's activities, such as eating at restau‐ rants, going to movie theaters, dancing, or hiking, the domestic partner and their relationship may suffer. The patient and significant other are asked to think about activities they once and might, yet again, enjoy together. Afterwards, the couple and therapist collaborate to develop a plan for increasing pleasurable conjoint activities. Reengaging in these activities may increase satisfaction with the relationship as well as reduce the patient's focus upon her symptoms.

A subsidiary aim of the conjoint sessions is to address the couple's communication about the patient's physical symptoms. Initially the therapist asks the couple to describe a few recent discussions about the patient's physical symptoms. Both members of the couple are asked to describe what each said about the symptoms and what each thought and felt at that time. Afterwards, the therapist summarizes and reflects upon the couple's communication about the patient's symptoms. Suggestions for alternative modes of interacting, that are less likely to reinforce illness behavior, are provided.

### **8. Conclusions**

can be witnessed by the patient. Occasionally patients will adopt and assimilate features of

Stage 3 of assertiveness involves communicating one's thoughts, feelings, desires, and needs with "I statements". The therapist suggests the patient use the following statement as a model, "I feel \_\_\_\_\_\_\_\_\_\_\_, when you \_\_\_\_\_\_\_\_\_\_\_." An example of content in this form is, "I felt worried when you didn't call to tell me you'd be late coming home from work last night." By making such a statement, this individual is taking responsibility for her feelings as opposed to blaming others (e.g., "You're so selfish not to have called"). Also, the statement is indisput‐ able since it is an expression of the patient's emotional reaction. The result is that the person being spoken to is somewhat less likely to react defensively than if attacked or explicitly criticized; the person addressed also may be less likely to attempt to refute the assertion itself.

The goals of including the significant other (domestic partner spouse) in treatment are to obtain additional information about the patient, to gain the significant other's support for the treatment, and to alter behaviors of the significant other that may reinforce the patient's symptoms or illness behavior. We view this aspect of the treatment to be so valuable that, even when working within our 10-session treatment format, we ask the patient's significant other

We typically invite the significant other to participate in a conjoint session within the first month of treatment. The rationale for meeting together with the patient and significant other is to encourage an open dialogue. In our experience, the therapeutic relationship is not always strong enough to tolerate a therapist's meeting separately with a significant other, as some patients readily become suspicious that "behind my back" others are minimizing their degree of discomfort. And, although we would like to begin deriving the benefits of including the significant other in treatment as soon as possible, for logistical reasons we typically delay the first conjoint session until we have had some time to develop rapport with the patient. We find

The focus of the conjoint session(s) includes discussions about the rationale for a "stress management" treatment and about how such a treatment could be maximally helpful to the patient. The therapist asks the significant other to comment on the impact of stress upon the patient's physical symptoms. Also, the impact of the patient's physical symptoms on the patient's and significant other's lives is examined. Here we aim to elicit information and to suggest that the significant other's involvement in treatment may benefit both parties. Reducing the likelihood that the significant other will undermine the treatment is critical.

After clarifying the treatment's rationale, the therapist attempts to determine whether the significant relationship has been impaired by the patient's illness. Somatizers' tendencies to withdraw from activities may not only diminish pleasure in their own lives, but also in their significant others' lives. When a patient foregoes couple's activities, such as eating at restau‐ rants, going to movie theaters, dancing, or hiking, the domestic partner and their relationship may suffer. The patient and significant other are asked to think about activities they once and

the third or forth session works well as an initial conjoint session.

this more assertive persona.

190 Mental Disorders - Theoretical and Empirical Perspectives

**7.7. Sessions with spouse or significant other**

to join us for 1 to 3 of those 10 sessions.

Somatic symptom disorder and related disorders are distressing, disabling, and costly disorders. Although the treatment of somatization and of somatic symptom disorder is in its infancy, there is sufficient evidence to believe CBT and ACBT have therapeutic value. Given the research conducted to date, we recommend CBT and ACBT as the treatments of choice for these disorders. A manualized 10-session version of our treatment [51] has been tested and found effective with patients diagnosed with very severe as well as more moderate levels of somatization [52, 53].

### **Author details**

Lesley A. Allen and Robert L. Woolfolk\*

\*Address all correspondence to: woolfolk@princeton.edu

Department of Psychology, Princeton University, Princeton, NJ, USA

### **References**


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**Chapter 9**

**The Bond We Share: Experiences of Caring for a Person**

The purpose of this chapter is to improve service providers' understanding of how to work with, include and understand the experience and expertise of mental health carers. This in‐ formation is useful for service providers in clinical mental health, psychosocial rehabilitation across government and non-government, and primary health care settings, and also for managers of services, to help determine training offered to their employees. It may also be useful for carers and carer support organisations, as well as for those who teach undergrad‐

**•** Understand the significant impact of caring for a person with a mental & physical health conditions, from the carer's perspective, and their day-to-day experience of caring;

**•** Understand how carers can contribute as positive partners with health care providers, in

**•** Critically analyse and reflect on their practice knowledge, skills and attitudes, in particu‐ lar, their consideration of carers' input to enhance the clinical and psychosocial outcomes

A review of the international and Australian research on mental health carers' experiences of caring for a loved one with mental illness provides a background to the issues. This is fol‐ lowed by a report on the results of a large study conducted in South Australia in 2010, with

and reproduction in any medium, provided the original work is properly cited.

© 2013 Lawn et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

**•** Recognise strategies within their own practice that engage and support carers.

**with Mental and Physical Health Conditions**

Sharon Lawn, Jeannette Walsh, Anne Barbara,

Margaret Springgay and Patricia Sutton

http://dx.doi.org/10.5772/46217

**1. Introduction**

Additional information is available at the end of the chapter

uate and postgraduate health professional students. After reading this chapter, readers will be able to:

supporting people with mental and physical health conditions;

mental health carers, to explore and examine the issues in more depth.

for people with mental and physical health conditions;

**Chapter 9**
