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Immature Defense Mechanisms, Somatization, and Attitudes Toward Seeking
Professional Psychological Help: A Reinvestigation of the Psychoanalytic Theory of
Somatization
A Dissertation Submitted to
The Faculty of the College of Arts and Science
In Candidacy for the Degree of
Doctor of Clinical Psychology
By
Brynne M. Mulloy
Chicago, Illinois
August 7, 2013
UMI Number: 3603774
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Approval
Date of Oral Defense: August 7, 2013
Doctoral Project Committee Chair
Name: Kimberly Dienes, Ph.D.
Position: Assistant Professor, Department of Psychology
Institution: Roosevelt University
Committee Members
Name: Catherine Campbell, Ph.D.
Position: Associate Professor, Director of Training, M.A. and Psy.D. Programs
Institution: Roosevelt University
Name: Steven Kvaal, Ph.D.
Position: Associate Professor
Institution: Roosevelt University
ii
Acknowledgments
First and foremost, I would like to thank my dissertation chair, Kimberly Dienes,
Ph.D. My interest in psychodynamic research and practice was sparked by Dr. Dienes’s
contagious enthusiasm. Without her, this dissertation topic would not have entered my
mind. Throughout graduate school, Dr. Dienes has served as a mentor to me, and I look
up to her.
I also wish to thank my dissertation committee members, Steven Kvaal, Ph.D. and
Catherine Campbell, Ph.D. Both Dr. Campbell and Dr. Kvaal have helped me to succeed
in so many ways, and I appreciate their guidance and support more than they know.
Their ideas and suggestions helped to shift my project from a mere concept into a
tangible task.
This project would not have been possible without help from my wonderful
husband, Ryan Mulloy, M.A. His support and assistance carried me though many
challenging circumstances. I would like to thank him for collecting and entering data
when I could not. I thank him for his support throughout graduate school and for always
believing in me.
To my dad, Stan Messner, M.D., thank you for fostering my stick-to-itiveness and
for teaching me “when the going gets tough, the tough get going.” Thank you Dad, for
supporting me and believing in me. I am aware of the sacrifices you made to provide me
with a strong education, and words cannot express the appreciation I have for you.
To my grandparents, Lorna and Jon Kardatzke, thank you for encouraging me and
for helping me grow into the young professional I am today. Lorna and Jon have
provided me with more love and support than one could hope for, and I appreciate them
iii
more than words can express. To my Aunt Kim Noller, your humor and support helped
me through many difficult times; thank you for your laughter, sensibility, and loving
heart. To Annie Mulloy, my friend and companion, thank you. Annie has been there for
me throughout my entire graduate school experience, and I treasure her. Many, many
thanks to all other family and friends; you are dear to my heart and appreciated.
iv
Abstract
Somatization is common in primary care, problematic for patients and providers,
and an enigma etiologically. Patients who persistently somatize are at high risk of
iatrogenic harm and are primary contributors to escalating health care costs. In order for
health professionals to intervene, the primary etiology of barriers to treatment as well as
particular barriers to treatment must be identified. The present study explored
connections between the etiology of somatization (immature defense mechanisms) and
current behavioral descriptions of somatization. Barriers to treatment (negative attitudes
towards professional psychological help) were also explored, with the prediction that
immature defense mechanisms would mediate the relationship between somatization and
negative attitudes. Participants included 302 patients of a family medicine clinic.
Somatization was measured on a continuum using the Health Attitudes Survey. Negative
attitudes were measured using the Attitudes Toward Seeking Professional Psychological
Help Scale—Short Form, and defense mechanisms were measured using the Defense
Style Questionnaire-40. Results indicated that, the more severe the somatization, the
more severe the use of immature defense mechanisms. Negative attitudes towards
professional psychological help were not related to somatization. Immature defense
mechanisms did not mediate between somatizing and attitudes towards professional
psychological help. Implications of these findings and directions for future research are
discussed. Clinical implications for primary care providers working with somatizing
populations are also presented.
v
Table of Contents
Title Page
i
Approval Page
ii
Acknowledgments
iii
Abstract
v
Table of Contents
vi
List of Tables
ix
List of Appendices
x
Chapter I: Introduction
11
Overview
11
Understanding Somatization
13
Outline
13
Chapter II: Literature Review
14
Epidemiology
16
Definition
16
History
17
Current Conceptualization of Somatization
20
Historical Conceptualization of Somatization
22
Defense Mechanisms and Somatization
24
Defense Mechanisms and Functional Somatic Symptoms
Barriers to Treatment: Attitudes
25
29
Attitudes Towards Physicians
29
Stigma and Attitudes
30
vi
Attitudes Towards Mental Health Professionals
31
Summary
32
Goals
32
Hypotheses
33
Chapter III: Methodology
33
Participants
33
Procedure
34
Measures
35
Demographics Questionnaire
35
Health Attitudes Survey
35
Attitudes Toward Seeking Professional Psychological Help
36
Defensive Style Questionnaire
38
Chapter IV: Results
40
Preliminary Analyses
40
Descriptive Data
40
Demographic Data and Group Comparisons
40
Main Hypotheses
43
Mediation
43
Sobel Test
44
Bootstrapping
45
Results of Bootstrapping Using Sobel Mediation Test
45
Supplementary Hypotheses
45
Chapter V: Discussion
49
vii
Limitations
54
Future Directions
55
Clinical Implications
59
Concluding Comment
62
References
63
Appendices
79
viii
List of Tables
Table 1: Descriptive Statistics
41
Table 2: Correlations Between Demographic Variables and Total Scores on
DSQ IDS, HAS Total, and ATS Total
42
Table 3: Between Subjects Effects of Univariate Regression and Bootstrapping
and Sobel Tests for Mediation
47
Table 4: Correlations Between Subscales of Health Attitudes Survey and
Defensive Style Questionnaire Immature Defense Subdomain
48
ix
List of Appendices
Appendix A: Implied Consent Form
79
Appendix B: Instructions for Participants
81
Appendix C: Personal Information Questionnaire
82
Appendix D: Defensive Style Questionnaire—40
84
Appendix E: Attitudes Toward Seeking Professional Psychological Help
88
Appendix F: Health Attitudes Survey
90
x
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Chapter I: Introduction
Overview
Somatization, characterized by the “production of recurrent and numerous
medical symptoms with no discernible organic cause,” (“Somatization,” 2013) is one of
the most common and perplexing problems affecting primary care medicine today
(Woolfolk & Allen, 2012; Woolfolk & Lesley, 2007). Current literature primarily
focuses on the behaviors and attitudes associated with somatization, such as stated
dissatisfaction with care, high utilization of care, and excessive health worry (Jyväsjärvi
et al., 2001; Noyes, Langbehn, Happel, Sieren, & Muller, 1999). The etiology of
somatization is poorly understood, and research on etiology has dwindled due to an
increased focus on the behavioral manifestations of psychosomatic syndromes (Duddu,
Isaac, & Chaturvedi, 2006). Therefore, this study examined the relationship between the
current behavioral descriptions of somatization and one of the oldest and most widely
known theories on causality: Somatization results from unconscious defensive strategies
used by the ego to defend against intolerable anxiety (Freud, 1937; Holder-Perkins &
Wise, 2001). By exploring connections between somatization and proposed causal
factors of somatization (defense mechanisms), the current study added to limited
literature exploring the etiology of somatization. There is a paucity of research on
defense mechanisms of primary care patients in the United States who present with
somatization. To address the gap in the literature, this study aimed to identify the
relationship between psychological defense mechanisms and somatization in order to
examine whether the relationship is worth further investigation. A significant
12
relationship between somatization and defense mechanisms may spark future interest and
investigation into the etiology of somatization.
In addition to a lack of understanding regarding the etiology of somatization,
there is a gap in psychosomatic research regarding particular barriers to treatment in
somatizing populations. One such barrier to treatment pertains to negative attitudes held
by somatizing individuals. Current research suggests that when somatization is present,
negative attitudes toward medical professionals are also present (Noyes et al., 1999). To
date, research had yet to examine whether this view extends to attitudes towards seeking
professional psychological help. To address this gap in the literature, this study included
a second component of investigation: the relationship between somatization and attitudes
towards seeking professional psychological help.
The current study explored potential links between somatization, immature
defense mechanisms, and attitudes towards professional psychological help, including the
extent to which attitudinal barriers to treatment are caused by immature defensive
processes. Bridging the gaps between somatization, defense mechanisms, and attitudes
towards seeking professional psychological help, a third component was added to the
study; the present study examined whether immature defense mechanisms explained
(mediated) the relationship between attitudes and somatization. For mediation to occur,
immature defense mechanisms must account for negative attitudes towards seeking
professional psychological help (Baron & Kenny, 1986; Preacher and Hayes, 2004). In
other words, if individuals engaging in somatization behavior were to interrupt their
continual use of immature defense mechanisms, they may cease to hold negative attitudes
13
toward professional psychological help (total mediation) or may hold less negative
attitudes towards professional psychological help (partial mediation).
Understanding Somatization
Somatization is often characterized as existing along a continuum, rather than as a
discrete disorder. According to Kirmayer and Robbins (1991), “there is no unique class
of psychosomatic disorders—only particular clinical instances in which psychosocial
factors play an overriding role in causing or aggravating a patient’s condition” (p. 2).
The mind-body connection is undeniable, and research indicates that, at one time or
another, most individuals will experience an impact of psychological stress on physical
health (Smith, Conway, & Cole, 2009). In the current study, the term somatization will
be used as a generic concept and should not be regarded as part of a particular diagnostic
category. The term “somatizer” will refer to individuals currently engaging in
somatization. Henceforth, the terms somatization and somatizer will refer to the current
behavioral descriptions of somatization.
Outline
Despite multiple efforts to conceptualize and treat somatization, researchers and
health professionals remain baffled by the construct and struggle to find solutions to this
ever-expanding psychiatric phenomenon. Leading researchers of psychosomatic
medicine label somatization as “medicine’s unresolved problem” (Lipowski, 1987, p.
294) and note that there is a pronounced “lack of consensus” in regards to its definition
and classification (Lamberty, 2008, p. 9). To introduce this unresolved problem, I first
address current research on somatization, providing a review of problems associated with
somatization, epidemiology, and definitions. Second, I address the complex history of
14
somatization research. I highlight why somatization remains an unsolved problem,
discussing the shift of focus from etiological speculation to behavioral description.
Finally, I discuss how researching primary defense mechanisms and attitudes towards
seeking professional psychological help may lead to a greater understanding of
somatization.
Chapter II: Literature Review
According to the Agency for Healthcare Research and Quality, the United States
of America spends more money on each individual’s healthcare than any other country in
the world (2002, as cited in Crane & Christenson, 2008). Cucciare and O’Donohue
(2003) argued that patients with high medical utilization are large contributors to the
ever-growing health care costs. Research has indicated a strong link between
somatization and high utilization (Hiller & Fichter, 2004). The multiple tests conducted
to find organic pathology in somatizers has an enormous impact on the escalating cost of
health care in the United States (Fink, Rosendal, & Olesen, 2005). In fact, according to
Cummings and VandenBos (1981), somatization in particular is causing the health care
system to go bankrupt.
Individuals who persistently engage in somatization often request specialty care;
tend to be treatment-resistant; and often request costly scans, surgeries, and
hospitalizations (Peters, Stanley, Rose, & Salmon, 1998). According to Fink (1992),
these procedures place somatizing individuals in the high-risk grouping for iatrogenic
harm. Patients with a long-term history of somatization are frequently grouped in
“serious risk” categories as the likelihood that they will develop illness, drug dependence,
15
or injury, from medical examinations and unnecessary treatment is substantial (Kirmayer
& Robbins, 1991; van der Feltz-Cornelis, Swinkels, Blankenstein, Hoedeman, &
Keuter, 2011).
Somatization is problematic for all individuals involved in the provision of health
care services. Somatization is associated with a more negative relationship between
primary care physician (PCP) and patient (Woolfolk & Allen, 2012). The process of
determining the etiology of symptoms is made difficult by communication problems
between somatizing individuals and health care professionals. Though the inability to
precisely articulate the contribution of psychosocial factors to somatic symptoms (a
sophisticated task) is common to most, somatizing individuals may have an unwillingness
to explore any contribution of psychosocial factors with their PCPs. This further blocks
PCPs from recognizing psychopathological etiologies. The doctor-patient relationship is
often harmed by negative communications which give rise to mutual frustration and
negative labeling. For example, physicians have labeled somatizers as “hateful” and
“crocks” (Groves, 1978; Lipsitt, 1970). Research has indicated that PCPs frequently
refer to somatizing individuals as problematic, while somatizing individuals label PCPs
as uncaring and unsatisfactory in their handling medical concerns (Blackwell & De
Morgan, 1996; Noyes et al., 1999). PCPs often view somatizing individuals as difficult
to manage and have had such pronounced problems treating such patients that specific
models have been created to aid PCPs in the treatment of somatizing individuals (Bass &
Benjamin, 1993).
16
Epidemiology
The epidemiology of somatization varies greatly, depending upon which
definition of somatization is used. When the restrictive criteria of the Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American
Psychiatric Association, 2000) is applied, rates of somatization tend to be quite low,
ranging from 0.2 to 2% for somatization disorder to 0.1 to 3% for conversion disorder.
However, the majority of clinicians do not utilize such circumscribed criteria when
researching and treating somatization (Lamberty, 2008). When somatization is more
broadly defined, prevalence rates increase, and the consistency of rates decreases. For
example, when characterized as the presentation of medically unexplained symptoms,
rates have been found to range from 20% to upwards of 60% (Elderkin-Thompson,
Silver, & Waitzkin, 1998; Steinbrecher, Koerber, Frieser, & Hiller, 2011).
Definition
Although researchers and health professionals have defined somatization
differently, many are in agreement that there are two features of somatization: First,
somatizing individuals present with recurrent and numerous medically unexplained
symptoms. Second, psychosocial stressors are antecedents of somatic presentation.
Lipowski’s (1988) landmark definition includes both chief factors and is used in the
present study. Lipowski defines somatization as “a tendency to experience and
communicate somatic distress and symptoms unaccounted for by pathological findings in
response to psychosocial stress and to seek medical help for them” (p. 1359).
One of the problems with this definition is that, without knowing Lipowski’s
(1988) intentions, one may assume that this definition connotes an unconscious defense
17
mechanism. However, Lipowski specifically noted that this definition “is descriptive,
does not imply a putative defense mechanism, and should not be confused with the
theoretical one” (p. 1359). In response to the plethora of popular and largely
psychoanalytic definitions of somatization, Lipowski aimed to change the connotation of
the term from one implying a hypothesized theoretical psychogenesis to one largely
descriptive and behavioral in nature. According to Lipowski (1988), somatization is not
to be considered a disorder nor diagnostic category, and researchers have commented that
Lipowski’s definition is “in line with the current concept of medically unexplained
symptoms” (Rosendal, Fink, Bro, & Olesen, 2005, p. 2). Much of the difficulty in
understanding somatization in research and practice is because the definition and
conceptualization of the construct has changed numerous times. Confusion regarding the
definition of somatization has resulted from its complex history.
History
There is debate over the genesis of psychosomatic syndromes (Lamberty, 2008).
However, historians suggest that the concept of somatization came into existence over
four thousand years ago in ancient Egypt (Smith, 1990; Woolfolk & Allen, 2007).
Egyptians theorized that, in women, the uterus would occasionally become displaced,
causing a “wandering womb,” resulting in a large number of pathologies (Fink, 1996).
This concept later appeared in a number of Grecian medical texts, one of which was
written by the Greek physician and forefather of modern medicine, Hippocrates.
Hippocrates did not revise the concept behind the wandering womb phenomenon but
relabeled the condition “hysteria.” The syndrome hysteria was acknowledged in many
18
European medical communities and evolved over time to become “more neurologically
oriented and less frankly misogynistic” (Lamberty, 2008, p. 4).
In the middle of the 19th century, the French psychiatrist Paul Briquet (1859)
authored a pilot thesis on hysteria, Traité Clinique et Thérapeutique de L’hystérie,
proposing that the syndrome occurred in both men and women and was a type of nervous
condition (Mai & Merskey, 1980; Woolfolk & Allen, 2007). Around the same time
period, Jean-Martin Charcot (regarded as the founder of modern neurology) concurred
with the neurological conceptualization of hysteria and began to converse with other
influential physicians regarding the syndrome. Two of these people, Pierre Janet and
Sigmund Freud, were influential in shifting the conceptualization of hysteria from
neurological in nature to psychological (Lamberty, 2008). Janet produced works on the
relationship between hysteria, suggestibility, and the subconscious, which became later
popularized by Freud (Lamberty, 2008).
At the end of the 19th century, Freud (1937) introduced the concept of
“conversion hysteria.” Freud stated, “in hysteria, the incompatible idea is rendered
innocuous by its sum of excitation being transferred into something somatic, for this I
should like to propose the name conversion” (p. 49). In other words, he believed that
anxiety associated with unconscious conflict was unacceptable to the individual and was
therefore concealed from conscious recognition. The somatic symptom was a mechanism
by which the unconscious could communicate psychological distress (Woolfolk & Allen,
2007). Uncomfortable sensations such as anxiety were converted into a more acceptable
form of suffering, somatic expression.
19
Though concepts underlying somatization had been present for centuries, the
official label of somatization came about in the early 1900s (Stekel, 1924). Soon after
conversion hysteria was popularized, the physician William Stekel coined the term
“somatization” and defined it as “a bodily disorder that arises as an expression of deepseated neurosis” (Smith et al., 2009). Sill adhering to a psychoanalytic framework for
explaining somatic symptoms, Stekel advocated the idea that, in somatization,
psychological problems are not consciously acknowledged and are instead converted into
somatic complaints. Stekel’s conceptualization of somatization (comparable to the
mechanism of conversion or a psychiatric defense mechanism) generated the recognition
of various psychosomatic disorders, which were then predominately treated with
psychoanalytic methods (Smith et al., 2009).
The zeal for psychoanalytic conceptualization and treatment dwindled due to
developments in the history of psychiatry. In the later 1900s, Emil Kraepelin (regarded
as the father of modern psychiatric diagnosis) attempted to dissuade health professionals
from adhering to a theoretical (i.e., psychoanalytic) understanding of psychosomatic
syndromes in favor of classifying diseases according to observable symptoms (Trede,
2007). It was Kraepelin who popularized the idea of abandoning the postulation of
etiologies to focus on the forecasting of outcomes (Decker, 2007). He viewed his way of
conceptualizing syndromes to be “clinical” in nature and the traditional way to be
“symptomatic” in nature and suggested that his students focus on hard evidence rather
than theoretical assumptions (Géraud, 2007; Trede, 2007). Kraepelin’s research and
classification of disease entities eventually led to a systematic nosography and away from
theoretical speculation (Palm & Möller, 2011).
20
Though Freud’s views remained popular in 20th century, Kraepelin’s synthesis of
mental disorders into a workable model, outlined in his pedagogical device, Compendium
der Psychiatrie (Kraepelin, 1883), greatly influenced the way psychiatric illness is
conceptualized and classified today. As Freud’s theories began to be largely questioned,
Kraepelin’s ideas gained in popularity (Trede, 2007). The effects in this shift can be seen
in the current classification, diagnosis, and treatment of psychosomatic syndromes (Palm
& Möller, 2011) where the behaviorally descriptive approach remains prominent.
Current Conceptualization of Somatization
In modern times, somatization is not typically conceptualized and defined as a
type of Freudian defense mechanism (Smith et al., 2009). Researchers and health
professionals take a behavioral and purely descriptive (somewhat Kraepelinian) approach
to the diagnosis, classification, and treatment of psychosomatic syndromes, largely free
from etiological speculation. Currently, somatization is most often explained and
observed as abnormal illness behavior (Chaturvedi, Desai, & Shaligram, 2006; Hiller &
Fichter, 2004; Kihlstrom & Kihlstrom, 1999). Pilowsky (1997) defined abnormal illness
behavior as the following:
An inappropriate or maladaptive mode of experiencing, evaluating or acting in
relation to one’s own state of health, which persists, despite the fact that a doctor
(or otherwise recognized social agent) has offered accurate and reasonably lucid
information concerning the person’s health status and the appropriate course of
management (if any), with provision of adequate opportunity for discussion,
clarification and negotiation, based on a thorough examination of all parameters
21
of functioning (physical, psychological, and social), taking into account the
individual’s age educational and sociocultural background. (p. 25)
Researchers and health professionals suggest that psychosomatic syndromes are
not best understood according to current somatoform nosology, but as degrees of severity
or frequency of this abnormal illness behavior (Kirmayer & Looper, 2006). These
behaviors would include excessive or inadequate responses to symptoms including, but
not limited to, hypochondriasis and somatization (Kirmayer & Looper, 2006). In this
way, somatization is currently understood in terms of the behaviors and number of
symptoms associated with the syndrome (i.e., recurrent medical visits, unnecessary
hospitalizations, chronic complaints about medical professionals, stated dissatisfaction
with state of health; Duddu et al., 2006; Kirmayer & Looper, 2006). Conceptualizing
somatization in this manner has allowed for identification of individuals engaging in
somatization. Recognition of such individuals can lead to avoidance of unnecessary tests
and procedures and might prevent continued abnormal illness behaviors (Chaturvedi et
al., 2006). However, the etiology and underlying factors that contribute to the
development and sustainment of somatization remain amorphous (Smith et al., 2009).
Additionally, the costs that somatization incurs for federally and state-funded programs,
medical professionals, society, and patients implies that a serious problem remains.
Individuals engaging in somatization continually return to health clinics (Hiller &
Fichter, 2002; Lipowski, 1988), which indicates that health care professionals are not
understanding and treating these patients in the most effective manner. Therefore, a
reinvestigation of the historical conceptualization of somatization is warranted and may
highlight a more effective way of conceptualizing and treating these patients.
22
Historical Conceptualization of Somatization
Previous to the introduction of the illness behavior definition, somatization was
largely considered a defense mechanism. When construed in this way, somatization is
defined as “the unconscious rechanneling of repressed emotions into somatic symptoms
as a form of symbolic communication” (Sutker & Adams, 2001, p. 216). Psychoanalytic
theory suggests that the physiological symptoms that occur in somatization function as
defenses against intolerable anxiety related to having a psychological problem (Kirmayer
& Robbins, 1996). Though defense mechanisms are a part of normal everyday life, they
become pathological when their continued use leads to maladaptive behavior and
consequences. The repeated use of the defense mechanism of somatization is thought to
lead to the maladaptive behavior of relentlessly seeking medical attention for a
psychological problem.
Freud (1894) provided the original definition of a defense mechanism. He
considered a defense mechanism a counterforce which serves to protect the individual
from overwhelming anxiety and unacceptable impulses (Cramer, 2006). Kohut (1977)
stated that the function of a defense mechanism is to protect the self (e.g., one’s selfesteem). In other words, defenses help individuals to cope with the realities of daily life.
In this way, they are adaptive. However, defense mechanisms can be used in
maladaptive ways which can lead to problems in daily functioning.
To date, there is not a consensus on the number and type of defense mechanisms.
Some theorists have attempted to classify defenses. Vaillant (1992) categorized defense
mechanisms according to developmental level: pathological, immature, neurotic, and
mature. Defenses at the pathological level include delusional projection, denial,
23
distortion, and splitting. These defenses are considered pathological because they often
kindle severe reality distortion, lead to social rejection, and are common in individuals
with severe and chronic mental health conditions (Valliant, 1992, 1994). Defenses at the
immature level include acting out, fantasy, idealization, passive aggression, projection,
projective identification, and somatization. Individuals who frequently utilize immature
defense mechanisms are often viewed as socially objectionable, difficult to handle, and
unrealistic. Persistent use of immature defense mechanisms leads to maladaptive coping
with daily life and is often associated with mental illness (Valliant, 1992, 1994).
Defenses at the neurotic level include displacement, dissociation, hypochondriasis,
intellectualization, isolation, rationalization, reaction formation, regression, repression,
and undoing. Neurotic defenses can be used in adaptive or maladaptive ways and can
either promote or hinder adaptive coping. Finally, defenses at the mature level include
altruism, anticipation, humor, identification, introjection, sublimation, and thought
suppression. These defenses are considered mature because they promote successful
coping and interpersonal effectiveness, support self-control, and are often utilized by
emotionally healthy individuals (Valliant, 1992). Largely based on Vailliant’s system,
the DSM-IV-TR (2000) recognized a provisional diagnostic axis for ego mechanisms of
defense. Additionally, McWilliams (1994) provided a simplified classification system of
ego mechanisms of defense, which labels defenses as either primitive or higher-order.
If unconscious defenses against anxiety provoking drives, wishes, or fears are
indeed involved in somatization, then the treatment of anxiety associated with these
unacceptable drives, wishes, or fears may provide a solution to the problem of somatizing
individuals taking up so much time and resources in the medical field. As noted above,
24
there is a scarcity of research on the relationship between the contemporary definition
and classification of somatization (behaviors and attitudes) and defense mechanisms. It
remains to be seen whether the use of defense mechanisms will predict somatization as
defined by the behavioral definition. However, a small number of studies have indicated
that the psychodynamic conceptualization of somatization may be worth a second look.
Defense Mechanisms and Somatization
Many definitions and discussions of somatization imply that defensive processes
are taking place, but there is little research on the connection. In fact, to this researcher’s
knowledge, there has been limited published articles investigating the role of defense
mechanisms in psychosomatic syndromes that indicate that there may be a relationship
between immature defense mechanisms and behaviorally defined somatization
(Deshpande, Vidya, Bendre, and Ghate, 2011; Xiao & Fu, 2006).
Deshpande and colleagues (2011) examined the defense mechanisms and
intellectual capacity of pediatric patients with medically unexplained symptoms in order
to understand how to categorize their pathophysiology and increase treatment
effectiveness. Participants included 17 children who met criteria for persistent
somatoform pain disorder according to the International Statistical Classification of
Diseases and Related Health Problems (ICD-10). Children who had a speculated organic
cause for their pain were excluded from the study. Each participant was given a semistructured interview that assessed demographic information, details about pain,
precipitating stressors, and individual and family history. One parent was present and
participated in each child’s interview. In addition to the interview, participants were
administered the Colored Progressive Matrices and the Children's Apperception Test.
25
Results from the Children’s Apperception Test indicated that pediatric patients with
somatoform pain disorder engaged in immature defense mechanisms. The most
commonly utilized defenses were denial, reaction formation, repression, and
rationalization. Although this study highlighted a possible connection between immature
defense mechanisms and psychosomatic presentation, it was limited by its small sample
size, exclusively pediatric population, and lack of a control group. The authors suggested
that future studies should include larger and more diverse samples.
Xiao and Fu (2006) also examined the defense mechanisms of individuals
diagnosed with persistent somatoform pain disorder as defined by the ICD-10.
Participants included 70 somatoform pain disorder patients and 60 healthy controls.
Defense mechanisms were measured via the Defensive Style Questionnaire. Results
indicated that individuals with persistent somatoform pain disorder used more immature
defense mechanisms and fewer mature defense mechanisms than healthy controls.
Somatization was a frequently utilized defense mechanism by the pain disorder group.
The research of Xiao and Fu indicated that immature defense mechanisms may play an
important role in the maintenance of somatoform disorders. Results indicated that the
relationship between somatization and immature defense mechanisms is worth further
investigation.
Defense Mechanisms and Functional Somatic Syndromes. Often, somatoform
disorders are used as alternative descriptors for functional syndromes (Manu, 1998).
Similar to psychosomatic syndromes, functional somatic syndromes are characterized by
various combinations of medically unexplained symptoms. Though there is the presence
of physiologic abnormality in many individuals with these syndromes, the number of
26
symptoms and intensity of suffering is often in excess of demonstrable biologic
abnormality (Barsky & Borus, 1999). The link between somatization and functional
somatic syndromes appears to be strong (Tsukui & Ebana, 2009). Though the assertion is
controversial, many researchers and health professionals believe that functional somatic
syndromes such as fibromyalgia, chronic fatigue syndrome, and inflammatory bowel
disease are characteristic expressions of somatization (Smith et al., 2009). Connections
have been made between psychical pain with no discernible organic cause and psychiatric
illness, and the same treatment has been suggested for both somatization and functional
somatic syndromes (Fjorback et al., 2012; Magni, 1987). Due to the overlap in these
syndromes, a review of the link between immature defense mechanisms and functional
somatic syndromes (an example of a categorical model imposed on a continuum) is
warranted.
The presence of somatization is common among chronic pain patients (BirketSmith, 2001). According to Tauschke, Merskey, and Helmes (1990), chronic pain may
arise from defense mechanisms. Sundbom, Henningsson, Holm, Söderbergh, and
Evengård, (2002) assessed the influence of defense mechanisms on patients diagnosed
with chronic fatigue syndrome. Participants included 13 individuals diagnosed with
chronic fatigue syndrome, two contrast groups of 19 individuals diagnosed with
conversion disorder, and 13 healthy controls. Results indicated that the chronic fatigue
group showed a defensive pattern characterized by denial, an immature defense
mechanism. Similar to Sundbom and colleagues, Egle and Porsch (1992) examined the
defense mechanisms of individuals with psychogenic pain who engage in abnormal
illness behavior. Results indicated that psychogenic pain patients who engage in
27
abnormal illness behavior such as “doctor shopping” were characterized by the use of
immature defense mechanisms. The term doctor shopping is used to describe the
behavior of consulting multiple medical professionals in a short amount of time in order
to attain prescription medications and other forms of medical treatment (Sansone &
Sansone, 2012). These patients were likely, in particular, to use the immature defense
mechanism “turning against the self.” When individuals engage in this immature defense
mechanism, they self-punish by directing adverse behavior towards themselves (“Turning
Against the Self,” 2013).
Fibromyalgia is a controversial diagnosis that manifests as a constellation of
symptoms such as fatigue, widespread pain, and atypical sensation sensitivity (Van
Houdenhove & Egle, 2004). This syndrome is believed by some to be a form of
somatization, as research has shown that individuals with fibromyalgia tend to somatize
psychological pain (Trygg, Lundberg, Rosenlund, Timpka, & Gerdle, 2002; Winfield,
2001). Landmark, Stiles, Fors, Holen, and Borchgrevink (2008) assessed whether
individuals with fibromyalgia relied more heavily on defense mechanisms compared to
controls. A secondary goal of the study was to examine the defense mechanisms of
fibromyalgia patients compared to those of individuals with major depressive disorder.
Participants included 25 fibromyalgia patients without a diagnosis of lifetime major
depressive disorder, 17 fibromyalgia patients with comorbid major depressive disorder,
24 individuals with a diagnosis of non-psychotic major depressive disorder, and 25
controls. The Life Style Index was used to measure defense mechanisms. Defense
mechanisms measured by the Life Style Index include compensation, denial,
displacement, intellectualization (including undoing, sublimation and rationalization),
28
projection, reaction formation, regression (including acting out and fantasy) and
repression (including introjections and isolation). The Life Style Index also includes a
total score which represents overall level of defensive functioning. Results indicated
large differences between the four groups in total number of defense mechanisms used.
Specifically, major depressive disorder patients and fibromyalgia patients with major
depressive disorder used more defenses than healthy controls. Fibromyalgia patients with
comorbid depression endorsed more items pertaining to the use of regression,
displacement, and compensation compared to healthy controls.
Research has indicated that psychogenic gastrointestinal symptoms often coexist
with inflammatory bowel disease (Simren et al., 2002). In fact, some researchers who
specialize in the study of psychosomatic syndromes believe that, in the field of
gastroenterology, irritable bowel syndrome is a form of somatic displacement (Smith et
al., 2009). Hyphantis and colleagues (2005) examined the association between
inflammatory bowel disease (including ulcerative colitis and Crohn’s disease) and
defense style. Utilizing the Defensive Style Questionnaire, a self-report measure which
groups defense mechanisms into immature, neurotic, and mature subdomains, Hyphantis
and colleagues found that Crohn’s disease patients were characterized by an immature
defensive profile. In a later study, Hyphantis and colleagues (2010) explored the
relationship between psychological distress, somatization, defense mechanisms, and
inflammatory bowel disease to determine how these factors influence quality of life. The
Defense Style Questionnaire and Life Style Index were used to assess defense
mechanisms. Hyphantis and colleagues suggested that, when faced with conditions that
29
involve chronic pain, individuals engage in the defense mechanism reaction formation,
which complicates their medical treatment.
In summary, research indicates that patients with medically unexplained
symptoms and symptoms in excess of what is expected given organic causes may use
more defense mechanisms than healthy controls (Landmark et al., 2008). More
specifically, individuals with functional somatic symptoms and with somatoform
disorders have been shown to use more immature defense mechanisms than those not
currently presenting with psychogenic pain (Xiao & Fu, 2006). This overuse of
immature defense mechanisms may lead to the over-utilization medical services to attain
relief from the unconscious anxiety. This over-utilization is problematic for health care
professionals and patients, as research has indicated a link between high utilization,
somatization, and negative doctor-patient relationships (Hahn, Thompson, Wills, Stern, &
Budner, 1994; Woolfolk & Allen, 2012).
Barriers to Treatment: Attitudes
Attitudes Towards Physicians. Individuals engaging in somatization are often
identified by their negative health attitudes (Noyes et al., 1999). Noyes et al. developed a
self-report scale, the Health Attitudes Survey, which identifies the presence of
somatization by the health behaviors and health attitudes patients endorse. Individuals
who engage in chronic somatization tend to have negative attitudes towards their
physicians, which serve as barriers to effective treatment. Noyes et al. found that,
compared to control subjects, somatizing individuals endorse more dissatisfaction with
medical care, agreeing that physicians do not seem to understand their health problems,
are unequipped to handle their health concerns, and provide less than satisfactory medical
30
treatment. Research findings such as these are common, indicating a strong link between
difficult physician-patient encounters and attitudes of somatizing individuals (Nagel,
McGrady, Lynch, & Wahl, 2003; Smith, 1985). In fact, because the presence of mutual
negative attitudes in the doctor-patient relationship is so evident, questionnaires such as
the Difficult Doctor-Patient Relationship Questionnaire (Hahn et al., 1994) have been
developed and used to identify problem patients such as those presenting with
psychosomatic issues. What remains somewhat of a mystery, is why somatizing
individuals have such negative attitudes towards their health care professionals.
Stigma and Attitudes. Somatization is a defense mechanism that may be used
to protect the individual from stigma associated with psychiatric problems. Supporting
this notion, research has indicated that fear of being stigmatized is one of the attitudes
common in individuals with psychogenic medical presentations (Freidl et al., 2007).
Patients with medically unexplained symptoms often endorse feeling stigmatized when a
mental health professional is involved in their treatment (Deshpande et al., 2011). The
feeling of being stigmatized may explain why somatizing individuals avoid contact with
mental health care professionals, though these professionals are likely more equipped to
deal with the underlying anxiety at the root of their immature defense mechanisms.
Freidl, Piralic-Spitzl, and Aigner (2009) examined the attitudes of patients diagnosed
with epileptic, dissociative, or somatoform pain disorders to better understand the role of
mental illness stigma in these populations. Participants included 45 patients diagnosed
with epileptic disorder, 14 patients with dissociative disorder, and 42 diagnosed with
somatoform pain disorder according to criteria specified by the DSM-IV-TR (American
Psychiatric Association, 2000). Participants were given Link’s Perceived Stigma
31
Questionnaire, an instrument used to detect attitudes towards psychiatric illnesses and
treatment. Results from Freidl et al.’s study indicated that individuals with epileptic,
dissociative, and somatoform pain disorders have a fear of stigma which can lead to
delayed psychiatric treatment seeking. The fear of being stigmatized occurred more
frequently among somatoform pain patients compared to individuals with dissociate or
epileptic conditions. Specifically, patients with somatoform conditions endorsed concern
regarding the social impact of having a mental illness. Results indicated that these
patients are preoccupied with a fear of rejection, which may lead them to ignore
psychiatric contributions to somatic symptoms.
Attitudes Towards Mental Health Professionals. Though research has
indicated a link between somatization, mental illness, and stigma (Friedl et al., 2007),
there is a paucity of research exploring somatizing individuals’ specific attitudes towards
mental health professionals. In other words, it remains largely unknown whether or not
somatizing individuals have specific negative perceptions of psychological service
providers. Some research has indicated that there is a relationship between somatization
and denial of need for mental health care (Kirmayer & Robbins, 1996); however,
research in this area is limited. Kirmayer and Robbins examined the attitudes of
individuals identified as somatizers and found that these individuals were significantly
less willing to accept that there were psychological aspects to their distress and were less
concerned with having an emotional problem compared to individuals identified as nonsomatizers. In summary, individuals who somatize frequently endorse negative attitudes
towards their physicians, less psychological distress, a high fear of stigma, and more
32
negative attitudes towards individuals with mental illness. Research has yet to examine
whether these views extend to mental health professionals.
Summary
Most of the literature on somatization has been devoted to the “what” of
psychosomatic behavior, exploring what types of behavior somatizing individuals present
with. To date, little research has explored the “why” of psychosomatic behavior,
exploring why treatment barriers exist. Researching potential connections between
immature defense mechanisms, current behavioral descriptions of somatization, and
negative attitudes mays help researchers and professionals understand what is driving and
maintaining the psychosomatic behavior. Once causal factors are identified, ways for
health professionals to intervene may become elucidated. In other words, if health
professionals are aware that immature defense mechanisms and negative attitudes
towards professional psychological help are barriers to treatment, interventions can be
aimed at countering these blockades. Improving treatment for somatizing individuals
may lead to improvement in functioning, less exposure to harm, more positive relations
between medical provider and patient and lower health care expenditures.
Goals
The present study had three main objectives: (a) to identify whether there is a
relationship between the modern conceptualization and definition of somatization
(abnormal illness behavior) and the historical definition (defense mechanisms), (b) to
examine whether the developmental level of psychological defense mechanisms predicts
somatization and attitudes towards seeking professional psychological help, and (c) to
determine if immature defense mechanisms explain the relationship between
33
somatization and attitudes towards seeking professional psychological help (meditational
hypothesis).
Hypotheses
Based on existing literature, I predicted that (a) higher scores of somatization (as
measured by total score on the Health Attitudes Survey) were associated with higher
scores of immature defense mechanisms (i.e., rationalization, autistic fantasy,
displacement, isolation, dissociation, devaluation, splitting, denial, passive aggression,
somatization, acting out, and projection) as measured by the Defensive Style
Questionnaire-40 immature defense subdomain score.
I also predicted that (b) higher scores of somatization were associated with more
negative mental health treatment attitudes (as measured by low scores on the Attitudes
Toward Seeking Professional Psychological Help Scale-Short Form).
Because immature defense mechanisms may be the primary etiology for barriers
to treatment (including negative attitudes), regarding mediation, I predicted that (c)
immature defense mechanisms would partially account for the relationship between
somatizing and negative treatment attitudes (partial mediation).
Chapter III: Methodology
Participants
Participants were 302 patients at a large, private family medicine practice in the
Midwest. In order to participate in the investigation, participants had to be at least 18
years of age and able to speak and read English. Due to missing data on some variables,
not all of the comparisons below included all participants. Thirty-seven percent of
participants (n = 110) were men and sixty-three percent were women (n = 189).
34
Participants ranged in age from 18 years to 85 years (M = 43.86, SD = 15.8). Patient’s
reported racial background was 91.1% White, 2.6% Latino, 1.7% African American,
1.3% American Indian, 1.0% Asian American, 1.3% Other. In terms of relationship
status, 70.9% were married or partnered, 18.2% single, 6% divorced, 3.3% other, 1.5%
separated. In terms of highest level of education, 41% had a college degree, 37.4%
completed high school, 12.9% had a graduate degree, 2.3% a professional degree, 1.7%
other, and 1.3% a doctoral degree. Mean annual family income approximated $67,000
(SD = 9,000).
Procedure
Over the course of 2 weeks, participants who were general admissions patients in
a family practice were approached and asked to participate by the primary investigator or
a research assistant. Participating patients were given a numbered packet that included a
consent form, an explanation of the study, and the questionnaires. Packets were not
linked in any way to identifiable information. The investigators were the only individuals
who had access to the completed forms and did not have information regarding the names
of those who accepted or declined. Interested patients were presented with a written
description of the study that did not explicitly mention that the study examined
somatization, defense mechanisms, and attitudes (see Appendix A). Patients completed
the questionnaires before the medical visit. After completion, the participants dropped
the survey into a large covered bin, which was removed and emptied daily.
35
Measures
Demographics questionnaire. Patients answered several demographic questions
including gender, age, ethnicity, total family income, relationship status, and highest level
of education (see Appendix C).
Health Attitude Survey. The Health Attitude Survey (HAS; Noyes et al., 1999)
is a 27-item self-report questionnaire designed to assess somatization (see Appendix F).
Although it has been used to distinguish somatizing patients from controls, it can be used
as a continuous measure, with higher scores representing a stronger presence of
somatization. The HAS is intended for use as a rapid screening device in clinical
settings. Each of the 27-items is scored on a Likert-type scale from 0 (strongly disagree)
to 4 (strongly agree). It was developed and tested in a primary care population by Noyes
and colleagues (1999). Items include questions related to psychological distress, somatic
symptom presentation, and health care utilization. Specifically, there are six dimensions
of somatization in the scale: dissatisfaction with care, frustration with ill health, high
utilization of medical care, excessive health worry, psychological distress, and discordant
communication of distress. Items on the psychological distress dimension include
statements such as “It is easy to relax and stay calm.” Items on the somatic symptom
presentation dimension include statements such as “I have trouble getting my mind off of
my health.” Items on the health care utilization dimension include statements such as “I
have seen many different doctors over the years” and “I do not go to the doctor often.”
Additional items on the scale focus on both interactions with PCPs and patient
satisfaction. Items on the dissatisfaction of care dimension include statements such as “I
have been satisfied with the medical care I have received” and “Doctors have taken my
36
health problems seriously.” These items were developed based on the literature on
somatization (Lipowski, 1986, 1987, 1988).
The HAS correlates at a moderate level with other measures of somatic symptoms
such as the Patient Questionnaire of the Primary Care Evaluation of Mental Disorders
(PRIME-MD), which is another measure of somatization (Kroenke, Spitzer, & deGruy,
1998; Noyes et al., 1999). Self-rated scores on the HAS were moderately correlated with
PCP ratings of somatization. In addition, Noyes and colleagues found the HAS to have
high predictive value as somatizing individuals scored higher on the HAS than healthy
controls. Results of Noyes and colleagues indicated that the HAS has adequate external
validity as demographic and illness variables influenced scores on subscales in forecasted
directions. Questions were worded both positively and negatively to reduce potential for
response bias. Results of Noyes and colleagues indicated that the HAS was acceptable
by patients, as fewer than 5% found the instrument to be unimportant, difficult, or
upsetting.
Noyes and colleagues (1999) also explored the utility of a brief version of the
HAS for distinguishing somatizing and nonsomatizing patients. After examining the
psychometric properties of the original 27-item version, in-depth analyses indicated that
eight items effectively discriminated between somatizing and nonsomatizing patients.
This brief version may be a more efficient screening tool for assessing for the presence of
somatization.
Attitudes Toward Seeking Professional Psychological Help Scale. The
Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPH; Fischer &
Turner, 1970) is a 29-item self-report questionnaire that was designed to assess mental
37
health treatment attitudes. The ATSPPH assesses an individual’s acknowledgment of the
need for psychological help (8 items), stigma tolerance (5 items), interpersonal openness
(7 items), and confidence in mental health professionals (9 items). The scale measures
the respondent’s tendency to accept or reject psychological help during a crisis or during
prolonged psychological distress. Fisher and Turner standardized this scale on a sample
consisting of college students and subsequent studies have indicated evidence for the
scale’s validity in more diverse populations (reviewed in Fisher and Farina, 1995).
According to Fisher and Farina (1995) the ATSPPH has good psychometric properties
and has demonstrated a high internal reliability (α = .86). To date, it is the only measure
for detecting mental health treatment attitudes that has been used and psychometrically
studied in numerous studies (Elhai, Schweinle, & Anderson, 2008).
For the ease of administration, the Attitudes Toward Seeking Professional
Psychological Help Scale-Short Form (ATSPPH-SF; Fischer & Farina, 1995) was used in
the current study (see Appendix E). The ATSPPH-SF is a 10-item measure that is
frequently used to measure mental health treatment attitudes. These 10 items constitute
two of the original scales factors: a) recognition of need for psychological help, and b)
confidence in mental health professionals. Items on the “recognition of need for
psychological help” dimension include statements such as “emotional problems resolve
by themselves.” Items on the “confidence in mental health professionals” include
statements such as “would find relief in psychotherapy if in emotional crisis.” The
authors modified the original scale for the purpose of developing a scale which would
yield one score that would represent the participant’s core attitude. Items are presented in
a 4-point Likert-type format. Participants’ responses range from 0 (disagree) to 3
38
(agree). Scores can range from 0 to 30, with higher scores indicating more positive
treatment attitudes.
Fischer and Farina (1995) standardized the ATSPPH-SF on a sample of medical
patients in a primary care clinic aged from 18 to 90 years. Fischer and Farina found that
the ATSPPH-SF had a 1-month test-retest reliability of 0.80, a correlation of .87 with the
original scale, and an internal consistency coefficient of .84. Elhai and colleagues (2008)
analyzed data from 389 primary care patients and found that the ATSPPH-SF
demonstrated a reliability coefficient alpha of 0.78. Constantine (2002) found that the
ATSPPH-SF demonstrated a Cronbach’s alpha of .83.
Defensive Style Questionnaire. The Defensive Style Questionnaire (DSQ-81;
Bond, Gardner, Christian, & Sigal, 1983) is a widely utilized self-report questionnaire
used to measure defense mechanisms. The DSQ has been found to have adequate
reliability and validity in both cross-sectional and longitudinal studies (Steiner, Araujo, &
Koopman, 2001). Since its creation, the DSQ has been through multiple revisions
(Cramer, 2006). The original DSQ (DSQ-81) consists of 81 items representing 14
defenses and 4 defensive styles. This version was modified into the DSQ-88 by Bond et
al. (1989). In this version of the DSQ, 14 of the original statements were dropped and 21
added, resulting in an 81-item questionnaire representing 20 defenses and 4 defensive
styles. The DSQ was further modified by Andrews, Pollock, and Stewart (1989) to both
establish correspondence with the original scale and create a shorter form. This
modification resulted in the DSQ-72, a 72-item measure, which was then reduced to a 36item measure, the DSQ-36. In 1993, Andrews et al. noted a problem with the DSQ-36;
the representation of the defenses was inconsistent. For example, one defense was
39
represented by 1 item while another represented by 10 items. This resulted in the
creation of the DSQ-40, which was used in the present study (see Appendix D).
In the DSQ-40, two items represent each of the defense mechanisms. The DSQ40 is composed of 40 items, which are rated on a Likert-type scale from 1 (strongly
disagree) to 9 (strongly agree), with higher scores indicating more frequent usage of that
defense. Defense mechanisms are group into three factors (immature, mature, and
neurotic). Mature defense styles include humor (items 4, 26), suppression (items 2, 25),
sublimation (items 3, 38), and anticipation (items 30, 35). Neurotic defense styles
include reaction formation (items7, 28), idealization (items 21, 24), pseudo-altruism
(items 1, 39), and undoing (items 32, 40). Immature defense styles include
rationalization (items 5, 16), autistic fantasy (items 14, 17), displacement (items 31, 33),
isolation (items 34, 37), dissociation (items 9, 15), devaluation (items 10, 13), splitting
(items 19, 22), denial (items 8, 18), passive aggression (items 23, 36), somatization
(items 12, 27), acting out (items 11, 20), and projection (items 6, 29). These factors have
been found to correlate at a high rate (.93 to .97) with the factor scores from the DSQ-72
(Cramer, 2006). The DSQ-40 has been found to have an average 1-month test-retest
reliability of .66 (Andrews, Singh, & Bond, 1993). The test-retest reliability of the
individual defenses has varied from .38 to .80. Although this is low, the retest reliability
for the individual defenses on other measures of psychological defense mechanisms are
lower (Cramer, 2006). Vulić-Prtorić (2008) found the immature defense mechanism
subdomain to have the highest reliability coefficient (.71) out of the three subdomains
(immature, neurotic, and mature). Ruuttu and colleagues (2006) found the DSQ-40 to
have adequate discriminate validity as outpatients reported more immature defensive
40
behavior than healthy controls. According to Andrews, Singh, and Bond (1993), the
DSQ-40 has adequate construct validity as evidenced by the scale’s usefulness in
discriminating between different clinical groups.
To demonstrate that the behavioral definition of somatization and the defense
mechanism somatization are theoretically different concepts, it was important to show
that the behavioral definition was measured, not the defense mechanism. In order to
improve discriminant validity, items assessing for the defense mechanism somatization
were removed from the DSQ-40. Specifically, item number 12 “I get physically ill when
things aren’t going well for me” and item number 27 “I get a headache hen I have to do
something I don’t like” were removed from analyses conducted.
Chapter IV: Results
Preliminary Analyses
Preliminary analyses using PASW Version 18.0.3 were conducted in order to test
for normality of distributions and potential outliers. No corrections or transformations
were necessary.
Descriptive Data
Descriptive statistics were calculated for all predictor, outcome, and mediator
variables (see Table 1).
Demographic Data and Group Comparisons
Pearson product-moment correlational analyses were conducted to assess the
relationship between education, age, office visits, annual income, and immature defense
mechanisms, somatization, and attitudes towards seeking professional psychological
help. Results of the correlational analyses indicated significant negative correlations
41
between several demographic variables and the Attitudes Toward Seeking Professional
Psychological Help total score, the Health Attitudes Survey total score, and the Defensive
Style Questionnaire immature defense subdomain (see Table 2).
Independent samples t tests were used to determine whether gender differences
existed in somatization. The mean score for women on the Health Attitudes Survey was
40.69 (SD = 13.92), and the mean score for men was 40.02 (SD = 11.33). Male and
female participants did not differ in amount of reported somatization; t (297) = -4.32, p =
.67.
Table 1
Descriptive Statistics
M
SD
HAS Total Score
38.14
11.85
DSQ Immature Subdomain Score
88.54
22.51
ATS Total Score
12.56
4.62
Note. N = 302.
42
Table 2
Correlations between Demographic Variables and Total Scores on DSQ IDS, HAS Total,
and ATS Total
DSQ IDS
HAS Total
ATS Total
R
-.10
-.11
-.20**
p
.08
.06
.00
n
301
301
301
R
-.21**
.06
-.03
p
.00
.31
.64
n
300
300
300
How often do you visit R
-.06
-.25**
.11
p
.29
.00
.07
n
297
297
297
R
-.14*
-.22**
-.07
p
.02
.00
.28
n
285
285
285
Education
Age
a health clinic
Annual Income
Note. DSQ IDS = Defensive Style Questionnaire immature defense subdomain score,
HAS Total = Health Attitudes Survey total score, ATS = Attitudes Towards Seeking
Professional Psychological Help—Short Form total score.
* p < 0.05 (2-tailed).
** p < 0.01 (2-tailed).
43
Main Hypotheses
Pearson product-moment correlational analyses were performed to determine
whether there was a relationship between immature defense mechanisms, as measured by
the Defensive Style Questionnaire immature defense subdomain score and somatization,
as measured by the Health Attitudes Survey total score. Results of the Pearson productmoment correlational analysis indicated a significant positive correlation (r = .33, p <
.01) between the Defensive Style Questionnaire immature defense subdomain score and
the Health Attitudes Survey total score, indicating that higher use of immature defense
mechanisms was associated with higher somatization.
Pearson product-moment correlational analyses were conducted to assess the
relationship between somatization, as measured by Health Attitudes Scale total score, and
attitudes towards professional psychological help, as measured by Attitudes Towards
Seeking Professional Psychological Help-Short Form total score. Results of the
correlational analysis indicated that the relationship was non-significant.
Mediation. Mediation is a statistical method used to identify the mechanism
(third variable) that explains the relationship between an independent and dependent
variable. Instead of looking directly at the relationship between an independent and
dependent variable, in mediation, a third causal variable (mediator) is influenced by the
independent variable and then influences the dependent variable (Baron & Kenny, 1986).
Research has indicated that the majority of studies which include a formal test of
mediation use the Baron and Kenny (1986) approach (MacKinnon et al., 2002).
According to the Baron and Kenny method, in order to test for mediation, the following
relationships must be examined: the relation between the predictor and the criterion
44
variables, the relation between the predictor and the mediator variables, and the relation
between the mediator and criterion variables. All of these correlations must be
significant in order for partial mediation to occur. For total mediation to occur, the
relation between predictor and criterion should be reduced to zero after controlling for the
relation between the mediator and criterion variables.
Sobel test. According to Preacher and Hayes (2004), there are “more
strategically rigorous methods by which mediation hypotheses may be assessed” (p. 718).
One such way of directly testing an indirect effect is the Sobel test (Sobel, 1982).
Whereas Baron and Kenny (1986) suggested using three separate regressions, Preacher
and Hayes (2004) suggested directly and indirectly testing the hypothesized mediator
through the indirect effect of independent variable on the dependent variable through the
proposed mediator. The Sobel test is thought to be an improvement over the traditional
Baron and Kenny method for several reasons. First, at the outset of statistical analysis
when assessing for indirect effects, the total effect of the independent variable on the
dependent variable does not have to be present. Unlike the Sobel test, the Baron and
Kenny approach would miss a significant indirect effect when there is no evidence for a
total effect (Preacher & Hayes, 2004). Second, according to Holmbeck, (2002, as cited in
Preacher & Hayes, 2004) one of the drawbacks to the Baron and Kenny method is that
this method has been shown to lead to Type I and Type II error. Third, compared to the
series of regression analyses suggested by Baron and Kenny, the Sobel test more
straightforwardly examines the mediation hypothesis by using a significance test
associated with the indirect effect rather than a series of individual significance tests
which do not directly examine the indirect effect (Preacher & Hayes, 2004). Finally,
45
research has indicated that the Baron and Kenny approach has low statistical power
compared to the Sobel method (MacKinnon et al., 2002; Preacher & Hayes 2004).
Bootstrapping. Bootstrapping is a nonparametric approach to hypothesis testing
and effect-size estimation useful for countering problems such as asymmetry and nonnormality in the sampling distribution of ab (Preacher & Hayes, 2004). Bootstrapping
can be utilized with smaller sample sizes, as it is not based on a large-sample theory.
This method increases confidence in smaller samples.
Results of Bootstrapping Using Sobel Mediation Test
For hypothesis three, bootstrapping using the Sobel mediation test was performed
to assess the indirect and direct influences among the independent and dependent
variables and mediator (see Table 3). Results revealed that the Health Attitude Survey
total score did not predict Attitudes Toward Seeking Professional Psychological Help
total score, thereby violating one of the assumptions of mediation according to Preacher
and Hays (2004). Neither total nor partial mediation occurred. Hypothesis 3 was
rejected.
The addition of the mediation analyses showed the directionality of the
relationship between somatization and immature defense mechanisms, indicating a
positive correlation. As the values on the Health Attitude Survey went up, so did the
values on the Defensive Style Questionnaire immature defense subdomain. More
specifically, for every point the Health Attitudes Scale went up, the Defensive Style
Questionnaire immature defense subdomain went up .33 of a point.
Supplementary Hypotheses
In order to further clarify the relationship between somatization and immature
46
defense mechanisms, and to assess whether similar results could be achieved using the
condensed version of the Health Attitudes Survey, additional correlational analyses were
performed. Correlational analyses were conducted to assess the relationship between
immature defense mechanisms and the Brief Health Attitudes Survey (a subset of items
in the Health Attitude Survey found to best discriminate somatizing patients from nonsomatizing patients). Results of the correlational analysis indicated a significant positive
correlation (r = .29, p < .01) between the Defensive Style Questionnaire immature
defense subdomain score and Brief Health Attitudes Scale total score indicating that
higher use of immature defense mechanisms was associated with higher somatization.
In order to determine whether or not the same results could be achieved using the
brief version of the Health Attitudes Survey, Correlational analyses were conducted to
assess the relationship between the Attitudes Towards Seeking Professional Help—Short
Form and the Brief Health Attitudes Survey. Results of the correlational analysis
indicated that the relationship was non-significant.
In order to clarify which components of the HAS drive the relationship between
somatization and immature defense mechanisms, correlational analyses were conducted
to assess the relationship between the six subscales of the Health Attitudes Survey and
Defensive Style Questionnaire immature defense subdomain. Results of the
correlational analysis indicated significant relationships between nearly all subscales at (p
< .01) indicating that the Health Attitudes Survey and Defensive Style Questionnaire
immature defense subdomain scale are highly correlated (see Table 4).
47
Table 3
Between subjects effects of univariate regression
Partial
Observed
Power
Source
Df
F
p
Eta Squared
Intercept
1
1.08
.300
.005
HAStotal * DSQimmature
45
0.78
.832
.148
.832
HAStotal
45
0.75
.875
.142
.807
1
0.31
.580
.002
.085
DSQimmature
1.79
Bootstrapping tests for mediation
Direct And Total Effects
Coefficient
SE
t
p
b (YX)
-.02
.02
-0.97
.33
b (MX)
.63
.10
6.07
.00
b (YM.X)
.05
.01
3.77
.00
b (YX.M)
-.05
.02
-2.18
.03
Indirect Effects and Significance Using Normal Distribution
Sobel
Value
SE
Z
p
.03
.01
3.20
.00
Bootstrap Results For Indirect Effect
Effect
M
SE
.03
.01
Note. 2-tailed tests. Y = ATS Total; X = HAS Total; M = DSQ IDS.
48
Table 4
Correlations between subscales of Health Attitudes Survey and Defensive Style
Questionnaire immature defense subdomain
DSQ IDS a
DWC
FIW
HUC
EHW
PD
DC
.15*
.17**
.06
.33**
.31**
.39**
.37**
.22**
.17**
.19**
.25**
.38**
.38**
.41**
.36**
.32**
.35**
.27**
.50**
.44**
DWC
FIW
HUC
EHW
PD
.48**
Note. DSQ IDS = Defensive Style Questionnaire immature defense subdomain score,
DWC = Health Attitudes Survey (HAS) Dissatisfaction with Care, FIW = HAS
Frustration with Ill Health, HUC = HAS High Utilization of Care, EHW = HAS
Excessive Health Worry, PD = HAS Psychological Distress, DC = HAS Discordant
Communication.
* p < 0.05 level (2-tailed).
** p < 0.01 level (2-tailed).
49
Chapter V: Discussion
This study is one of the very few studies to investigate the relationship between
somatization and psychological defense mechanisms in a primary care population. First,
this study found a significant and positive relationship between immature defense
mechanisms and somatization. Results of the present study showed that, as endorsement
of somatization increases, so does endorsement of the use of immature defense
mechanisms; confirming hypothesis one, that higher scores of somatization are associated
with higher scores of immature defense mechanisms. This result is in accordance with
previous findings, which indicate a relationship between unconscious defensive processes
and somatization (Deshpande et al., 2011; Xiao & Fu, 2006). Results from the current
study suggest that the relationship between current behavioral descriptions of
somatization and the theoretical, psychoanalytic conceptualization of psychosomatic
processes is worth further investigation.
The unique aspect of findings from the present study is that continuous variables
were used to indicate whether increases in somatization are related to increases in
immature defenses. Though research has examined the relationship of defense
mechanisms to medically unexplained symptoms, very little research has specifically
examined the construct of somatization and its relationship to immature psychiatric
defenses and, to this researcher’s knowledge, studies have yet to explore somatization
and psychological defenses on continua.
Present findings showed that somatization was an independent positive predictor
of immature defense mechanisms among primary care patients. Somatization predicted
nearly all domains of the Defensive Style Questionnaire—40 immature defense
50
subdomain. Specifically, the following five out of six domains of the Health Attitudes
Survey were positively correlated with the Defensive Style Questionnaire—40 immature
defense subdomain: dissatisfaction with care, frustration will ill health, excessive health
worry, psychological distress, and discordant communication. One subdomain of the
Health Attitudes Survey, utilization of care, was not related to the endorsement of
immature defenses. One possible reason for this was that sample size did not provide
adequate power, as approximately 67% of participants chose not to answer items
pertaining to number of office visits.
These novel findings support the notion that somatization might have a strong
influence in number of defenses endorsed. In other words, the behavioral description of
somatizing individuals (communicating psychological pain though bodily complaints and
continually seeking medical help for bodily symptoms) is indicative of specific defensive
processes, such as rationalization, autistic fantasy, displacement, isolation, dissociation,
devaluation, splitting, denial, passive aggression, somatization, acting out, and projection.
This connection may lead to a better understanding of psychosomatic behavior. For
example, somatizing individuals may use the defense mechanism splitting to
unconsciously split the mind and body into two unrelated constructs. If this is the case,
an explanation of the connection between mind and body may prove beneficial when
working with somatizing individuals. In summary, the link found between somatization
and immature defense mechanisms provides support for the psychoanalytically based
etiological theory of somatization: Somatizing individuals may control anxiety by
unconsciously converting psychological distress into somatic symptoms. Understanding
51
the connection between the etiology and behavioral manifestations of somatization may
lead to more effective and efficient treatment for these individuals.
Findings did not support the hypothesis that somatization is related to negative
attitudes towards professional psychological help; disconfirming hypothesis two.
Findings of the current study were in contrast to those in the literature, which suggest that
individuals who present with psychosomatic syndromes have negative attitudes towards
mental illness and seeking mental health treatment (e.g., Freidl et al., 2009). However, to
this researcher’s knowledge, there is limited literature (if any) exploring somatizing
patients’ particular attitudes towards the personal usefulness of psychological help or
somatizers’ opinions of the abilities of mental health professionals. One possible reason
for the lack of association between somatization and negative attitudes may be that
negative attitudes towards health providers specifically applies to medical personnel and
does not extend to mental health providers (e.g., psychologists, social workers). Current
literature suggests that individuals with somatization disorders have labeled physicians in
a negative manner (Groves, 1978; Lipsitt, 1970); but there is little to no information
regarding somatizer’s opinions of particular mental health workers (e.g., psychologists,
social workers). It is also possible that individuals who persistently somatize endorse
negative attitudes specifically towards mental illness (Bridges et al., 1991) but not
towards mental health professionals who treat the psychiatric problems.
Furthermore, I hypothesized that immature defense mechanisms would mediate
the relationship between somatization and attitudes toward seeking professional
psychological help. Results indicated that increased somatization was not related to
increased negative attitudes towards professional psychological help. According to
52
Baron and Kenny (1986), this violates an assumption of mediation: There must be a nonzero relationship between the independent variable and the dependent variable.
Therefore, partial mediation was not present and hypothesis three was rejected.
Results indicated a significant relationship between immature defense
mechanisms and somatization using the Brief Health Attitudes Survey. There was not a
relationship between negative attitudes and somatization using the Brief Health Attitudes
Survey. These findings replicated the findings with the extended version of the Health
Attitudes Survey, further solidifying original findings that, though there is a significant
relationship between immature defense mechanisms and somatization, there is not a
significant relationship between somatization and attitudes towards professional
psychological help. These results suggest that the brief version may be a more efficient
screening tool for assessing for the presence of somatization in future studies.
This study demonstrated how rates of somatization, immature defense
mechanisms, and attitudes towards professional psychological help differed as a function
of demographic characteristics. Attitudes towards professional psychological help
differed as a function of education: As level of education increased, negative attitudes
towards professional psychological help decreased. This finding is consistent with the
literature which indicates that higher levels of education are associated with willingness
to engage in psychological help-seeking behavior (Horwitz, 1987). The use of immature
defense mechanisms differed as a function of age and annual income: As age increased,
use of immature defense mechanisms decreased. This finding is consistent with previous
literature, which indicates that, as age increases, so does the use of mature defense
mechanisms (Vaillant, 1993). Results of the current study indicated that, as annual
53
income increased, use of immature defense mechanisms decreased. Lastly, somatization
differed as a function of annual income and office visitations: As annual income
increased, somatization decreased. This finding is consistent with the literature, which
suggests that individuals of low socioeconomic status tend to engage in somatization
more frequently than those of a higher economic class (Kirmayer & Looper, 2007; Smith,
Monson, & Livingston, 1985). Results of the current study also indicated that, as office
visits increased, endorsement of somatization decreased. This finding is in sharp contrast
to an overwhelming volume of literature which suggests that somatizing individuals are
frequent attenders and chronically utilize unnecessary medical services (Cucciare &
O’Donohue, 2003; Hiller & Fichter, 2004; Peters et al., 1998). There are several possible
factors that may have influenced this puzzling finding. First, physicians have been
known to have aversive reactions to somatizing individuals (Hiller & Fichter, 2004).
Therefore, it is possible that health care providers were reluctant to continue scheduling
somatizing individuals, which led to a decrease in office visits. The current study
specifically measured primary care office visits. Somatizing individuals frequently seek
out multiple types of medical assistance. It is possible that frequency of visitation was
not captured as visitations to specialty clinics and multiple PCP clinics were not assessed.
Women are often over-represented among individuals with psychosomatic
disorders, both in the community and clinical settings (4th ed., text rev.; DSM–IV–TR;
American Psychiatric Association, 2000; Woolfolk & Allen, 2007). However, in the
current study, women were not more likely to somatize than men. Results of the current
study are in contrast with the literature, which suggests that women are more likely to
report psychosomatic symptoms and seek help for such symptoms (Kroenke & Spitzer,
54
1998). The current results are supported by other findings (Hartung & Widiger, 1998),
which suggest that prevalence rates of somatoform spectrum disorders may be biased,
with females receiving more somatoform diagnoses than men. There was not a
relationship between age and amount of somatization endorsed. This finding is in
contrast to current literature, which indicates that amount of somatization increases with
age (Kocalevent, Hinz, & Brähler, 2013).
Limitations
This study had several limitations. First, the exclusive use of self-report measures
is a potential limitation. Research has indicated that self-report defense mechanism
assessments may be problematic (Davidson & MacGregor, 1998). Participants are
required to assess their own defensive processes, which some suggest may result in
problems with the validity of self-report measures (Mehlman & Slane, 1994). Research
has indicated a link between somatization and fear of stigmatization (Freidl, 2007). It is
possible that, due to fear of stigma, patients underreported symptoms, attitudes, and
defenses, distorting the results.
In addition, as this investigation relied on voluntary participation, it is possible
that results were biased by the self-selection of respondents. There may have been
substantial differences between individuals who chose to participate and individuals who
chose not participate. It is also possible that the presence of physiological illness or
injury skewed results. State effects may have influenced results. For example, if patients
were feeling particularity good or bad at the time they filled out the questionnaire, their
answers may have been more negative or positive. The presence of abnormal illness
behavior in somatizing patients is a potential limitation of this study. Individuals
55
engaging in somatization have been found to present with health complaints (e.g., pain,
discomfort) in excess of that which is expected by medical professionals (Pilowsky,
1997). It is possible that some somatizing individuals refused to participate in the study
due to somatic pain or discomfort.
In addition, there may be problems with the external validity of this study.
Participants included a predominately White sample (91.1%). Because of this, the results
may not generalize to other populations.
Participants included primary care patients at a large family medicine clinic in the
Midwest. Primary care may attract a particular type of somatizer and clinically
significant somatizers may have been missed due to population limitations. This study
did not include patients visiting other branches of medicine. Results may have differed if
tertiary care patients, or patients referred to more specialized consultative care were
included.
Finally, this study measured conceptually distinct, yet potentially overlapping,
constructs. However, multicolinearity is assumed in simple mediation. To reduce
potential problems with discriminant validity, items pertaining to somatization were not
included in the DSQ-40. Due to altercations made, the reliability and validity of the
version used in this study may not be representative of the reliability and validity
evidenced in previous studies of the DSQ-40.
Future Directions
The goal of the present study was to determine whether or not there was a
relationship between the use of immature defense mechanisms and somatization. Though
the current study identified a relationship between these two variables, the mechanism
56
underlying the relationship between somatization and immature defense mechanisms is
unclear. Future investigations might consider a more in-depth analysis of the relationship
between defensive styles and somatization to determine causal factors of the relationship.
Specifically, it would be beneficial for future research to clarify whether the use
immature defense mechanisms causes an increase in psychosomatic behavior or whether
increased psychosomatic behavior causes an increase in use of immature defense
mechanisms. Additionally, future studies should include comparisons of mature defense
mechanisms versus immature defense mechanisms in terms of their predictive power
regarding somatization to determine whether or not immaturity of defenses is the critical
issue.
Participants in the current study were all patients of a primary care clinic. Current
literature indicates that somatization occurs in almost all medical specialty clinics, with
patient populations at each branch of medicine having unique and distinctive
presentations of somatization (Smith, Conway, & Cole, 2009). For example, according
to Smith et al., the characteristic expression of somatization in internal medicine patients
is thought to be chronic fatigue syndrome; in dentistry, temporomandibular joint
syndrome. Further research examining the type and number of psychiatric defenses and
presence of psychosomatic behavior of patients in specialty clinics would aid in further
establishing the relationship of the two variables across settings and would contribute to
the understanding of connections between medically unexplained symptoms,
somatization, and unconscious defensive processes.
Participants in the current study were predominately White. Somatization occurs
worldwide (Kirmayer & Looper, 2007). However, some geographic regions and
57
ethnocultural groups have a higher prevalence rate of somatization and somatoform
disorders (Kirmayer & Young, 1998). Future studies should investigate defense
mechanisms, somatization, and attitudes using a more ethnically and culturally diverse
population. In addition, results of the current study indicated multiple relationships
between various demographic variables and somatization, attitudes towards professional
psychological help, and immature defense mechanisms. Future studies further assessing
specific relationships among these variables would lead to a greater understanding of the
effects of demographics on mental health attitudes, somatization, and defensive
processes. Also regarding demographics, in future studies, regressions should be utilized
to enter in significant control variables.
To this researcher’s knowledge, the current study was the first study to utilize a
primary care setting to explore the relationship of somatization to attitudes towards
mental health professionals. Future studies should address the relationship between
immature defense mechanisms and attitudes towards medical professionals. The general
idea is that individuals engaging in somatization have negative attitudes towards medical
personnel (Noyes et al., 1999). Though current literature highlights connections between
somatization and negative attitudes towards physicians (Blackwell, & De Morgan, 1996;
Noyes et al., 1999), to this researcher’s knowledge, research has yet to be conducted to
determine if there is a relationship between somatization, negative attitudes towards
physicians, and immature defense mechanisms. This research would help health
professionals further understand the barriers to effective care (such as unconscious
defensive processes), particular attitudes somatizing patients are likely to have, and ways
to provide services to individuals who present with these particular barriers.
58
The current study relied solely on patient self-report. Future studies should be
designed to replicate, validate, and expand findings using non-self-report methodology.
For example, the presence of somatization could be determined using the PRIME-MD
(Spitzer et al., 1994). The PRIME-MD is a somatization detection tool comprised of a
patient questionnaire and a clinician evaluation guide. Alternatively, the Structured
Clinical Interview for DSM-IV-TR (SCID) could be utilized to confirm the presence of
somatization (First, Spitzer, Gibbon, & Williams, 2002). The SCID is an established
diagnostic tool considered standard in clinical research. Future research could impose the
category of “somatizer” onto the dimension somatization to compare groups regarding
level of immature defenses and amount of negative attitudes. In other words, future
studies could utilize cut-off scores for somatization from the HAS to examine
characteristics of somatizers versus healthy controls. These investigations could include
qualitative data for more in-depth responses.
As there was multicolinearity between the Defensive Style Questionnaire—40
immature defense subdomain and the Health Attitudes Survey, future investigation of
these scales is warranted to identify whether somatization and immature defenses are
similar constructs.
There are multiple theories of effective treatment strategies for somatization,
some empirical investigation of them, and little conclusive evidence. Many researchers
and professionals support the notion that a cognitive-behavioral approach to somatization
may be effective (Woolfolk & Allen, 2007), while some believe in a mindfulness-based
approach (Fjorback et al., 2012, 2013), and others in a more psychodynamically-based
approach (Smith et al., 2009). In addition, some suggest that a psychopharmacological
59
approach may be appropriate, highlighting the usefulness of antidepressants (Stahl,
2003). Whatever the treatment preference, most researchers and clinicians agree that
there is no standard of care for somatization. Future research should determine how
effective particular therapies are for treating individuals who persistently somatize as
well as the effective components of each approach.
Clinical Implications
Researchers and practitioners are in agreement that somatization is not only
common in primary care but is on the rise (Kirmayer & Looper, 2007; Smith et al., 2009).
Due to this, health professionals need to develop specific plans for the identification,
management, and treatment of somatizing individuals. Results of the current study
indicated that, as somatization increases, so does the use of immature defense
mechanisms. This finding has implications for the treatment of somatizing individuals.
Mental and medical health professionals should bear in mind the underlying
defensive personality structure of somatizing individuals as adapting treatment to fit
patient’s level of defensive functioning has been found to increase alliance between
practitioner and patient (Despland, de Roten, Despars, Stigler, & Perry, 2001). It would
be useful for individuals involved in the provision of health care services to understand
the psychological processes associated with immature defenses so that treatment could be
adjusted accordingly. If health practitioners are aware that individuals currently
somatizing are likely to make use of particular defenses, they may be able to intervene in
a manner which reduces the need for utilizing immature defenses.
It is helpful for health professionals to know that the use of immature defenses is
a negative indicator of level of interpersonal and global functioning (Cramer, 1991,
60
2000). The persistent use of immature defense mechanisms in adulthood is associated
with psychopathology (Vaillant, 1994). In fact, research has indicated that individuals
who are found to have a psychiatric disorder are likely to engage in the use of immature
defense mechanisms (Cramer, 2000). Knowing that the use of immature defense
mechanisms often leads to emotional problems and the inability to cope effectively
(Vaillant, 1998), the groundwork for treatment should be established early in the
treatment process and should include a combination of interventions.
The groundwork for treatment involves a multidisciplinary approach. According
to Kirmayer and Looper (2007) “all symptoms should be treated as having both
physiological and psychological dimensions and should be investigated and treated at
multiple levels” (p. 439). Current literature supports this notion and indicates that a
combination of consultation and collaboration between PCP, patient, and mental health
professional in conjunction with psychopharmacological agents may be key (Anderson &
Winkler, 2006; Matalon, Nahmani, Rabin, Maoz, & Hart, 2002; van der Feltz-Cornelis,
Hoedeman, Keuter, & Swinkels, 2012).
When working with the somatizing patient, the language used when referring a
patient to psychotherapy is essential, as somatizing patients tend to have high levels of
concern regarding stigma associated with mental health treatment (Freidl, 2007). Results
of the current study indicated that, as somatization increases, negative attitudes towards
psychotherapists or psychotherapy does not increase. Therefore, it is possible that stigma
prevents somatizing individuals from engaging in psychotherapy, not negative attitudes
towards the mental health professionals. To decrease stigma, explanations and examples
provided by medical professionals of the mind-body connection may be particularly
61
important. For example, using phrases such as “you’re more prone to headaches with
daily stressors and having someone assist you in managing your stress level could help to
manage your headaches” may be particularly useful. As negative attitudes towards
psychological help are not barriers to treatment, health care professionals could aim at
countering the underlying anxiety or stigma attached to attending mental health facilities.
As somatizing individuals do not think poorly of mental health professionals, decreasing
anxiety and stigma may increase acceptance of referral to psychological care. These
referrals could greatly reduce somatization in primary care, reducing the escalating health
care costs.
When working with chronic somatizers, referring for treatment of the underlying
psychiatric problem is a complex and delicate process and the addition of immature
defensive processes only complicates referral further. However, psychotherapy has been
found to decrease immature defense use (Cramer & Blatt, 1993). Research indicates that,
among patients with psychiatric problems, patients who show the most reduction in use
of immature defenses show greatest improvement in functioning (Cramer, 1999). Being
able to change the defense mechanism itself may lead to changes in psychosomatic
behavior.
Psychosomatic behavior may be maintained by the particular use of immature
defenses. According to Perry, Presniak, and Olson (2013), even a small amount of
gratification earned from engaging in the defense mechanism maintains the use of the
mechanisms. When physicians are confronted with psychogenic symptoms, it can be
quite easy for them to focus solely on the somatic symptom and ignore the context in
which the symptom is presented. Certainly, from a professional perspective, it is
62
important to routinely inquire about somatic symptoms and investigate for the presence
of injury and illness. However, it is imperative that physicians be aware of the potential
of psychogenic origins to problems and should consider patients with somatization to be
a large portion of their caseload.
Concluding Comment
The conceptualization of somatization as a form of abnormal illness behavior
seems to be growing in popularity. This shift away from the traditional psychoanalytic
conceptualization of somatization may be premature, as the current study indicated that
links between behaviors found in somatizing individuals and unconscious defensive
processes exist. The etiological mechanisms (psychiatric defenses) of somatization
should be included in future empirical research.
The health field today continues to have difficulty with the integration of the
biological and psychodynamic approach to somatization (Lamberty, 2008).
Unfortunately, many health providers tend to work dualistically, treating individuals as if
the mind and body are separate components. Results from the current study suggest that
an integrative approach, merging psychoanalytic concepts with systematic observation,
may benefit both health professional and patient.
63
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington, DC: Author.
Anderson, F. J., & Winkler, A. E. (2006). Benefits of long-term Fibromyalgia Syndrome
treatment with a multidisciplinary program. Journal of Musculoskeletal Pain, 14,
11-25. doi:10.1300/J094v14n04_03
Andrews, G., Pollock, C., & Stewart, G. (1989). The determination of defense style by
questionnaire. American Journal of Psychiatry, 46, 455-460.
doi:10.1001/archpsyc.1989.01810050069011
Andrews, G., Singh, M., & Bond, M. (1993). The Defense Style Questionnaire. Journal
Of Nervous And Mental Disease, 181, 246-256. doi:10.1097/00005053199304000-00006
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in
social psychological research: Conceptual, strategic, and statistical
considerations. Journal of Personality and Social Psychology, 51, 1173-1182.
doi:10.1037/0022-3514.51.6.1173
Barsky, A. J., & Borus, J. F. (1999). Functional somatic syndromes. Annals of Internal
Medicine, 1, 910-921. Retrieved from
http://www.psy.med.br/textos/somatizacao/somatic_syndromes.pdf
Bass, C., & Benjamin, S. (1993). The management of chronic somatization. British
Journal of Psychiatry, 162, 472-480. doi: 10.1192/bjp.162.4.472
Birket-Smith, M. (2001). Somatization and chronic pain. Acta Anaesthesiologica
Scandinavica, 45, 1114-1120. doi: 10.1034/j.1399-6576.2001.450911.x
64
Blackwell, B., & De Morgan, N. P. (1996). The primary care of patients who have bodily
concerns. Archives of Family Medicine, 5, 457-463. Retrieved from
http://www.clockss.org/clockss/Archives_of_Family_Medicine
Bond, M., Gardner, S. T., Christian, J., & Sigal, J. J. (1983). Empirical study of self-rated
defense styles. Archives of General Psychiatry, 40, 333-338.
doi:10.1001/archpsyc.1983.01790030103013
Bond, M., Perry, J. C., Gautier, M., Goldenberg, M., Oppenheimer, J., & Simand, J.
(1989). Validating the self-report of defense styles. Journal of Personality
Disorders, 3, 101-112. doi: 10.1521/pedi.1989.3.2.101
Bridges, K., Goldberg, D., Evans, B., & Sharpe, T. (1991). Determinants of somatization
in primary care. Psychological Medicine, 21, 473-483. doi:
10.1017/S0033291700020584
Chaturvedi, S. K., Desai, G., & Shaligram, D. (2006). Somatoform disorders,
somatization, and abnormal illness behavior. International Review of Psychiatry,
18, 75-80. doi:10.1080/09540260500467087
Constantine, M. G. (2002). Predictors of satisfaction with counseling: Racial and ethnic
minority clients' attitudes toward counseling and ratings of their counselors'
general and multicultural counseling competence. Journal of Counseling
Psychology, 49, 255-263. doi:10.1037/0022-0167.49.2.255
Cramer, P. (1999). Future directions for the Thematic Apperception Test. Journal of
Personality Assessment, 72, 74-92. doi:10.1207/s15327752jpa7201_5
Cramer, P. (2000). Defense mechanisms in psychology today: Further processes for
65
adaptation. American Psychologist, 55, 637-646. doi: 10.1037//0003066X.55.6.637
Cramer, P. (2006). Protecting the self: Defense mechanisms in action. New York, NY:
The Guilford Press.
Cramer, P., & Blatt, S. J. (1993). Change in defense mechanisms following intensive
treatment, as related to personality organization and gender. In U. Hentschel, G. J.
W. Smith, W. Ehlers, & J. G. Draguns (Eds.), The concept of defense mechanisms
in contemporary psychology (pp. 310-320). New York, NY: Springer Verlag
Books.
Crane, R. D., & Christenson, J. D. (2008). The medical offset effect: Patterns in
outpatient services reduction for high utilizers of health care. Contemporary
Family Therapy, 30, 127-138. doi:10.1007/s10591-008-9058-2
Cucciare, M. A., & O'Donohue, W. (2003). Integrated care and the high utilizer: An
explication of medical usage patterns and their role in the healthcare crisis. In N.
A. Cummings, W. T. O'Donohue, K. E. Ferguson (Eds.), Behavioral health as
primary care: Beyond efficacy to effectiveness: A report of the Third Reno
Conference on the Integration of Behavioral Health in Primary Care (pp. 95110). Reno, NV US: Context Press.
Cummings, N. A., & VandenBos, G. R. (1981). The twenty-year KaiserPermanente
experience with psychotherapy and medical utilization: Implications for national
health policy and national health insurance. Health Policy Quarterly, 1, 159-175.
Davidson, K. & MacGregor, M. W. (1998). A critical appraisal of self-report defense
66
mechanism measures. Journal of Personality, 66, 965-992. doi: 10.1111/14676494.00039
Decker, H. S. (2007). How Kraepelinian was Kraepelin? How Kraepelinian are the neoKraepelinians?--from Emil Kraepelin to DSM-III. History Of Psychiatry, 18, 337360. doi:10.1177/0957154X07078976
Deshpande, S. S., Vidya, G., Bendre, N. S., & Ghate, M. R. (2011). Children with
medically unexplained pain symptoms: Categorization and effective pain
management. Indian Journal of Psychological Medicine, 33, 163-166. doi:
10.4103/0253-7176.92065
Despland, J., de Roten, Y., Despars, J., Stigler, M., & Perry, J. (2001). Contribution of
patient defense mechanisms and therapist interventions to the development of
early therapeutic alliance in a brief psychodynamic investigation. Journal Of
Psychotherapy Practice & Research, 10, 155-164. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/journals/1745/
Duddu, V., Isaac, M. K., & Chaturvedi, S. K. (2006). Somatization, somatosensory
amplification, attribution styles and illness behavior: A review. International
Review of Psychiatry, 18, 25-33. doi:10.1080/09540260500466790
Egle, U. T., & Porsch, U. (1992). Psychogenic pain conditions. Defense structure and
taxonomic subgroups. Der Nervenarzt, 63, 281-288. Retrieved from
http://link.springer.com/journal/115
Elderkin-Thompson, V., Silver, R. C., & Waitzkin, H. (1998). Narratives of somatizing
and non somatizing patients in a primary care setting. Journal of Health
Psychology, 3, 407-428. doi: 10.1177/135910539800300309
67
Elhai, J. D., Schweinle, W., & Anderson, S. M. (2008). Reliability and validity of the
Attitudes Toward Seeking Professional Psychological Help Scale-Short Form.
Psychiatry Research, 159, 20-329. doi:10.1016/j.psychres.2007.04.020
Fink, P. (1992). Surgery and medical treatment in persistent somatizing patients. Journal
of Psychosomatic Research, 36, 439-447. Retrieved from
http://dx.doi.org/10.1016/0022-3999(92)90004-L
Fink, P. (1996). From hysteria to somatization: A historical perspective. Nordic Journal
of Psychiatry, 50, 353-363. doi:10.3109/08039489409084959
Fink, P., Rosendal, M., & Olesen F. (2005). Classification of somatization and functional
somatic symptoms in primary care. Australian and New Zealand Journal of
Psychiatry, 39, 772-781. doi: 10.1111/j.1440-1614.2005.01682.x
First, M. B., Spitzer, R. L., Gibbon, M., and Williams, J. B. W. (2002). Structured
Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient
Edition. (SCID-I/P) New York: Biometrics Research, New York State Psychiatric
Institute.
Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychological
help: A shortened form and considerations for research. Journal of College
Student Development, 36, 368-373.
Fischer, E. H., & Turner, J. L. (1970). Orientations to seeking professional help:
Development and research utility of an attitude scale. Journal of Consulting and
Clinical Psychology, 35, 79-90. doi:10.1037/h0029636
Fjorback, L., Arendt, M., Ørnbøl, E., Walach, H., Rehfeld, E., Schröder, A., & Fink, P.
68
(2012). Mindfulness therapy for somatization disorder and functional somatic
syndromes — randomized trial with one-year follow-up. Journal of
Psychosomatic Research, 74, 31-40. doi:10.1016/j.jpsychores.2012.09.006
Fjorback, L., Carstensen, T., Arendt, M., Ørnbøl, E., Walach, H., Rehfeld, E., & Fink, P.
(2013). Mindfulness therapy for somatization disorder and functional somatic
syndromes: Analysis of economic consequences alongside a randomized trial.
Journal of Psychosomatic Research, 74(1), 41-48.
doi:10.1016/j.jpsychores.2012.09.010
Freidl, M., Piralic-Spitzl, S., & Aigner, M. (2009). The stigma of mental illness:
Anticipation and attitudes among patients with epileptic, dissociative, or
somatoform pain disorders. Directions in Psychiatry, 29, 331-339. Retrieved
from http://informahealthcare.com/loi/irp
Freidl, M. M., Spitzl, S., Prause, W. W., Zimprich, F. F., Lehner-Baumgartner, E.,
Baumgartner, C. C., & Aigner, M. M. (2007). The stigma of mental illness:
Anticipation and attitudes among patients with epileptic, dissociative or
somatoform pain disorder. International Review of Psychiatry, 19, 123-129.
doi:10.1080/09540260701278879
Freud, S. (1962). The neuro-psychoses of defense. In The Standard Edition of the
Complete Psychological Works of Sigmund Freud, Volume III (1893-1899): Early
Psycho-Analytic Publications (pp. 41-61).
Freud, S. (1937). The Ego and the Mechanisms of Defense. London: Hogarth
Press and Institute of Psycho-Analysis.
Géraud, M. M. (2007). Emil Kraepelin: Un pionnier de la psychiatrie moderne (à
69
l'occasion du cent cinquantième anniversaire de sa naissance). L'encéphale: Revue
De Psychiatrie Clinique Biologique Et Thérapeutique, 33, 561-567.
doi:10.1016/S00137006(07)92053-9
Groves, J. E. (1978). Taking care of the hateful patient. New England Journal of
Medicine, 298, 883-887. Retrieved from http://www.nejm.org/
Hahn, S. R., Thompson, K. S., Wills, T. A., Stern, V., & Budner, N. S. (1994). The
difficult doctor patient relationship: Somatization, personality, and
psychopathology. Journal of Clinical Epidemiology, 47, 647-657. Retrieved from
http://www.sciencedirect.com/science/article/pii/0895435694902127
Hersen, M., Turner, S. M., & Beidel, D. C. (Eds.). (2007). Adult psychopathology and
diagnosis (5th ed.). Hoboken, NJ: John Wiley & Sons, Inc.
Hiller, W., & Fichter, M. (2004). High utilizers of medical care: A critical subgroup
among somatizing patients. Journal of Psychosomatic Research, 56, 437-443.
doi: 10.1016/S0022-3999(03)00628-7
Holder-Perkins, V., & Wise, T. N. (2001). Somatization disorder. In K. A. Phillips (Ed.),
Somatoform and Factitious Disorders (pp. 1-21). Washington, DC: American
Psychiatric Publishing Inc.
Horwitz, A. V. (1987). Help-seeking processes and mental health services. New
Directions for Mental Health Services, (36), 33-45. doi:10.1002/yd.23319873605
Hyphantis, T., Antoniou, K., Tomenson, B., Tsianos, E., Mavreas, V., & Creed, F.
(2010). Is the personality characteristic “impulsive sensation seeking” correlated
to differences in current smoking between ulcerative colitis and Crohn's disease
70
patients?. General Hospital Psychiatry, 32, 57-65.
doi:10.1016/j.genhosppsych.2009.09.002
Hyphantis, T. N., Triantafillidis, J. K., Pappa, S., Mantas, C., Kaltsouda, A., Cherakakis,
P…Mavreas, V. G. (2005). Defense mechanisms in inflammatory bowel disease.
Journal of Gastroenterology, 40, 24-30. doi: 10.1007/s00535-004-1491-x
Jyväsjärvi, S., Joukamaa, M.,Väisänenc, E., Larivaara, P., Kivelä, S., & KeinänenKiukaanniemia, S. (2001). Somatizing frequent attenders in primary health care.
Journal of Psychosomatic Research, 50, 185-192. Retrieved from
http://www.sciencedirect.com/science/article/pii/S0022399900002178
Kihlstrom, J. F., & Kihlstrom, L. (1999). Self, sickness, somatization, and systems of
care. In R.J. Contrada & R. D. Ashmore (Eds.), Self, social identity, and physical
health: Interdisciplinary explorations (pp. 23-42). New York, NY US: Oxford
University Press.
Kirmayer, L. J., & Looper, K. J. (2006). Abnormal illness behavior: Physiological,
psychological, and social dimensions of coping with distress [Electronic
Version]. Current Opinion in Psychiatry, 19, 54-60. Retrieved from
http://journals.lww.com/copsychiatry/Abstract/2006/01000/Abnormal_illness_be
haviour__physiological,.11.aspx
Kirmayer L. J., & Looper, K. J. (2007). Somatoform Disorders. In Adult
Psychopathology and Diagnosis (pp. 410-472). Hoboken, NJ: John Wiley &
Sons, Inc.
Kirmayer, L. J., & Robbins, J. M. (1991). Current concepts of somatization: Research
and clinical perspectives. Washington, DC: American Psychiatric Press, Inc.
71
Kirmayer, L., & Robbins, J. (1996). Patients who somatize in primary care: A
longitudinal study of cognitive and social characteristics. Psychological
Medicine: A Journal of Research In Psychiatry and the Allied Sciences, 26, 937951. doi:10.1017/S0033291700035273
Kirmayer L. J., & Young, A. (1998). Culture and somatization: clinical, epidemiological,
and ethnographic perspectives. Psychosomatic Medicine, 60, 420-430. Retrieved
from http://www.p-s-f.com/psf/IMG/pdf_Somatization_Kirmayer_Young.pdf
Kohut, H. (1977). The restoration of the self. New York: International Universities Press.
Kraepelin, E. (1883). Compendium der psychiatrie. Leipzig: Metzger & Wittig.
Kroenke, K., Spitzer, R. L., deGruy, F. V., & Swindle, R. (1998). A symptom checklist to
screen for somatoform disorders in primary care. Psychosomatics, 39, 263-272.
doi: 10.1016/S0033-3182(98)71343-X
Lamberty, G. L., (2008). Understanding somatization in the practice of clinical
neuropsychology. Oxford, NY: Oxford University Press.
Landmark, T., Stiles, T. C., Fors, E. A., Holen, A., & Borchgrevink, P. C. (2008).
Defense mechanisms in patients with fibromyalgia and major depressive disorder.
The European Journal of Psychiatry, 22, 185-193. doi:10.4321/S021361632008000400001
Lipowski, Z. J. (1987). Somatization: The experience and communication of
psychological distress as somatic symptoms. Psychotherapy and Psychosomatics,
47, 160-167. doi:10.1159/000288013
72
Lipowski, Z. (1988). Somatization: The concept and its clinical application. American
Journal of Psychiatry, 145, 1358-1368. Retrieved from
http://ajp.psychiatryonline.org/article.aspx?articleID=165467
Lipsitt, D. R. (1970). Medical and psychological characteristics of “crocks.” Psychiatry
Medicine, 1, 15-25. doi: 10.2190/38CT-C0Q8-9L6R-XN6Q
MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002).
A comparison of methods to test mediation and other intervening variable effects.
Psychological Methods, 7, 83-104. doi:10.1037/1082-989X.7.1.83
Magni, G. (1987). On the relationship between chronic pain and depression when there is
no organic lesion. Pain, 31, 1-21. doi: 10.1016/0304-3959(87)90002-9
Mai, F. M., & Merskey, H. (1980). Briquet's Treatise on hysteria: A synopsis and
commentary. Archives of General Psychiatry, 37, 1401-1405. Retrieved from
http://archpsyc.jamanetwork.com/journal.aspx
Manu, P. (1998). Definition and etiological theories. In P. Manu (Eds.), Functional
somatic syndromes: Etiology, diagnosis, and treatment. Cambridge, UK:
Cambridge University Press.
Matalon, A., Nahmani, T., Rabin, S., Maoz, B., & Hart, J. (2002). A short-term
intervention in a multidisciplinary referral clinic for primary care frequent
attenders: Description of the model, patient characteristics and their use of
medical resources. Family Practice, 19, 251-256. doi:10.1093/fampra/19.3.251
McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure
in the clinical process. New York, NY: The Guilford Press.
Mehlman, E., & Slane, S. (1994). Validity of self-report measures of defense
73
mechanisms. Assessment, 1, 189-197. doi:10.1177/1073191194001002009
Nagel, R. W., McGrady, A., Lynch, D. J., & Wahl, E. F. (2003). Patient-physician
relationship and service utilization: Preliminary findings. Primary Care
Companion to the Journal of Clinical Psychiatry, 5, 15-18. Retrieved from
http://www.psychiatrist.com/pcc/pccpdf/v05n01/v05n0104.pdf
Noyes, R., Langbehn, D. R., Happel, R. L., Sieren, L. R., & Muller, B. A. (1999). Health
Attitude Survey: A scale for assessing somatizing patients. Psychosomatics, 40,
470-478. doi: 10.1016/S0033-3182(99)71184-9
Palm, U., & Möller, H. (2011). Reception of Kraepelin's ideas 1900–1960. Psychiatry
And Clinical Neurosciences, 65, 318-325. doi:10.1111/j.1440-1819.2011.02226.x
Perry, J., Presniak, M. D., & Olson, T. R. (2013). Defense mechanisms in schizotypal,
borderline, antisocial, and narcissistic personality disorders. Psychiatry:
Interpersonal And Biological Processes, 76(1), 32-52.
doi:10.1521/psyc.2013.76.1.32
Peters, S., Stanley, I., Rose, M., & Salmon, P. (1998). Patients with medically
unexplained symptoms: Sources of patients’ authority and implications for
demands on medical care. Social Science and Medicine, 46, 559-565.
doi:10.1016/S0277-9536(97)00200-1
Pilowsky, I. (1997). Abnormal illness behavior. West Sussex: England: John Wiley &
Sons Ltd.
Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect
effects in simple mediation models. Behavior Research Methods, Instruments &
Computers, 36, 717-731. doi:10.3758/BF03206553
74
Rosendal, M., Fink, P., Bro, F., & Olesen, F. (2005). Somatization, heartsink patients, or
functional somatic symptoms? Towards a clinical useful classification in primary
health care. Scandinavian Journal of Primary Health Care, 23, 3-10. doi:
10.1080/02813430510015304
Ruuttu, T., Pelkonen, M., Holi, M., Karlsson, L., Kiviruusu, O., Heilä, H., Tuisku, V.,
Tuulio-Henriksson, A., & Marttunen, M. (2006). Psychometric properties of the
defense style questionnaire (DSQ-40) in adolescents. Journal of Nervous and
Mental Disorders, 194, 98-105. doi: 10.1097/01.nmd.0000198141.88926.2e
Sansone, R. A. & Sansone, L. A. (2012). Doctor shopping: A phenomenon of many
themes. Innovations in Clinical Neuroscience, 9, 42-46. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552465/
Simren, M., Axelsson, J., Gillberg, R., Abrahamsson, H., Svedlund, J., & Björnsson, E.
S. (2002). Quality of life in inflammatory bowel disease in remission: The impact
of IBS-like symptoms and associated psychological factors. American Journal of
Gastroenterology, 97, 389-396. doi: 10.1016/S0002-9270(01)04037-0
Smith, L. W., Conway, P. W., & Cole, J. O. (2009). The mind-body interface in
somatization: When symptom becomes disease. Lanham, MD: The Rowman &
Littlefield Publishing Group, Inc.
Smith, G. R. (1990). Somatization disorder in the medical setting. Washington, DC US:
American Psychiatric Association.
Smith, G., Monson, R. A., & Livingston, R. L. (1985). Somatization disorder in men.
General Hospital Psychiatry, 7(1), 4-8. doi:10.1016/0163-8343(85)90003-9
Smith, R. C. (1985). A clinical approach to the somatizing patient. The Journal of Family
75
Practice, 21, 294-301.
Sobel, M. E. (1982). Asymptotic confidence intervals for indirect effects in structural
equation models. Sociological Methodology, 13, 290-312. Retrieved from
http://ripl.faculty.asu.edu/wp-content/uploads/2013/02/Sobel-1982.pdf
Somatization [Def. 1]. (2013). In Oxforddictionaries.com. Retrieved March 30, 2012,
from http://oxforddictionaries.com/us/definition/american_english/somatization
Spitzer, R. L., Williams, J. W., Kroenke, K., Linzer, M., deGruy, F., Hahn, S. R., & ...
Johnson, J. G. (1994). Utility of a new procedure for diagnosing mental disorders
in primary care: The PRIME-MD 1000 study. JAMA: Journal of The American
Medical Association, 272, 1749-1756. doi:10.1001/jama.272.22.1749
Stahl S.M. (2003). Antidepressants and somatic symptoms: Therapeutic actions are
expanding beyond affective spectrum disorders to functional somatic syndromes.
Journal of Clinical Psychiatry, 64, 745–746. Retrieved from
http://www.psychiatrist.com/brainstorms/br6407.pdf
Steinbrecher, N., Koerber, S., Frieser, D., & Hiller, W. (2011). The prevalence of
medically unexplained symptoms in primary care. Psychosomatics, 52, 263-271.
doi: 10.1016/j.psym.2011.01.007
Steiner, H., Araujo, K. B., & Koopman, C. (2001). The response evaluation measure
(REM-71): A new instrument for the measurement of defenses in adults and
adolescents. American Journal of Psychiatry, 158, 467-473.
doi:10.1176/appi.ajp.158.3.467
Stekel, W. (1924). Peculiarities of behavior (Vols. 1-2). London: Williams and Norgate.
Sundbom, E., Henningsson, M., Holm, U., Söderbergh, S., and Evengård, B. (2002).
76
Possible influence of defenses and negative life events on patients with chronic
fatigue syndrome: A pilot study. Psychological Reports, 91, 963-878.
doi:10.2466/PRO.91.7.963-978
Sutker, P. B., & Adams, H. E. (2001). Comprehensive handbook of psychopathology (3rd
ed.). New York, NY US: Kluwer Academic/Plenum Publishers.
Tauschke, E., Merskey, H., & Helmes, E. (1990). Psychological defense mechanisms in
patients with pain. Pain, 40, 161-170. doi: 10.1016/0304-3959(90)90067-N
Trede, K. (2007). 150 years of Freud-Kraepelin dualism. Psychiatric Quarterly, 78, 237240. doi:10.1007/s11126-007-9036-0
Trygg, T., Lundberg, G., Rosenlund, E., Timpka, T., & Gerdle, B. (2002). Personality
characteristics of women with fibromyalgia and of women with chronic neck,
shoulder, or low back complaints in terms of Minnesota Multiphasic Personality
Inventory and Defense Mechanism Technique modified. Journal of
Musculoskeletal Pain, 10, 33-55. doi:10.1300/J094v10n03_03
Tsukui, K., & Ebana, S. (2009). Somatization and FSS. Nihon Rinsho, Japanese Journal
of Clinical Medicine, 67, 1677-1682. Abstract retrieved from PubMed datebase.
Turning Against the Self. (2013). In http://behavenet.com. Retrieved August 9, 2013
from http://behavenet.com/turning-against-self
Vaillant, G. E. (1992). Ego mechanisms of defense: A guide for clinicians and
researchers. Washington, DC: American Psychiatric Press.
Vaillant, G. E. (1993). The Wisdom of Ego. Cambridge, MA: Harvard University Press.
Vaillant, G. E. (1994). Ego mechanisms of defense and personality psychopathology.
Journal of Abnormal Psychology, 103, 44–50. doi: 10.1037/0021-843X.103.1.44
77
van der Feltz-Cornelis, C. M., Hoedeman, R., Keuter, E. W., & Swinkels, J. A. (2012).
Presentation of the Multidisciplinary Guideline Medically Unexplained Physical
Symptoms (MUPS) and Somatoform Disorder in the Netherlands: Disease
management according to risk profiles. Journal of Psychosomatic Research, 72,
168-169. doi:10.1016/j.jpsychores.2011.11.007
van der Feltz-Cornelis, C. M., Swinkels, J. A., Blankenstein, A.H., Hoedeman, R., &
Keuter, E.J. (2011). [The Dutch multidisciplinary guideline entitled 'Medically
unexplained physical symptoms and somatoform disorder']. Ned Tijdschr
Geneeskd, 155.
Van Houdenhovea, B., & Egle, U. T. (2004). Fibromyalgia: A stress disorder? Piecing
the biopsychosocial puzzle together. Psychotherapy and psychosomatics, 73, 267275. doi: 10.1159/000078843
Vulić-Prtorić, A. (2008). Psihometrijska validacija upitnika obrambenih stilova DSQ40—Preliminarno istraživanje. Socijalna Psihijatrija, 36, 49-57. Retrieved from
http://www.unizd.hr/Portals/12/Nastavnici/Anita%20Vuli%C4%87Prtori%C4%87/Znanstveni%20radovi/32.%20DSQ-40.pdf
Winfield, J. B. (2001). Does pain in Fibromyalgia reflect somatization? Arthritis
&Rheumatism, 44, 751-753. doi:10.1002/15290131(200104)44:4<751::AlANR130>3.0.CO;2-Z
Woolfolk, R. L., Allen, L. A. (2007). Treating somatization: A cognitive-behavioral
approach. New York, NY: The Guilford Press.
Woolfolk, R. L. & Allen, L. A. (2012). Cognitive behavioral therapy for somatoform
disorders. In I. Oliveira (Eds.), Standard and innovative strategies in cognitive
78
behavior therapy (p. 117-144). Rijeka, Croatia: InTech.
World Health Organization. (1993). ICD-10, the ICD-10 classification of mental and
behavioral disorders: Diagnostic criteria for research. Geneva: World Health
Organization.
Xiao, L., & Fu, S. (2006). Defense mechanism and its related factors in patients with
persistent somatoform pain disorder. Chinese Journal of Clinical Psychology, 14,
395-396. Retrieved from http://www.oriprobe.com/journals/zglcxlxzz.html
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Appendix A
Implied Consent Form
Implied Informed Consent Form for Social Science
Research Roosevelt University
Principal Investigator:
Brynne Messner, MA, Graduate Student
360 E South Water #2412
Chicago, IL 60601
(316)393-2040; [email protected]
Faculty Supervisor:
Dr. Kimberly Dienes
430 South Michigan Ave.
AUD 1255-Tower
Chicago, IL 60605
(312)341-3799; [email protected]
Other Investigator(s):
Ryan Mulloy, Graduate Student
1. Purpose of the Study: The purpose of this research study is to explore the opinions
of patients in primary care clinics. For example, the current study will examine
patient’s satisfaction with current medical care and patient’s attitudes towards various
health care professionals.
2. Procedures to be followed: You will be asked to answer questions on three different
surveys. You will also be asked to answer basic demographic questions.
3. Duration: It will take approximately 15-20 minutes to complete the surveys.
4. Statement of Confidentiality: Your participation in this research is confidential.
Your name is in no way linked to your responses and the information you provide
will NOT be available to the medical staff or submitted to your patient file.
5.
Right to Ask Questions: Please contact Brynne Messner, MA at (316) 393-2040
with questions or concerns about this study. If you would like to speak with someone
other than the researchers, you may contact the Roosevelt University Institutional
Review Board at (312) 853- 4774. If you have questions about the rights of
participants, you may contact the Faculty Research Ethics Officer at (312) 341-2440.
80
6. Voluntary Participation: Your decision to be in this research is voluntary. You can
stop at any time. You do not have to answer any questions you do not want to answer.
If you would like to discontinue the study, please place the packet in the covered bin
labeled “surveys” or hand the questionnaire back to the individual who distributed it
to you.
You must be 18 years of age or older to take part in this research study. Completion and
return of the survey implies that you have read the information in this form and consent
to take part in the research. Please keep this form for your records or future reference.
81
Appendix B
Instructions for Participants
●Complete all pages of this packet at any time during your visit today.
●When you are finished, please place this questionnaire into the envelope provided and
put it into the box labeled “questionnaires” before you leave.
●Thank you for your participation!
82
Appendix C
Personal Information Questionnaire
Today’s date: _______________
What is your gender (circle one)?
Male
Female
What is your age? ______
What is your ethnicity (check one)?
□ White (Not Hispanic)
□ Black, African-American
□ American Indian or Alaska Native
□ Asian
□ Hispanic or Latino
□ Native Hawaiian or Other Pacific Islander
□ Other: _____________________
How often do you visit this clinic?
The WWFP clinic:
□ this is the first time
□ once a week
□ once a month
□ every six months
□ every year
□ every two years or longer
The emergency room:
□ this is the first time
□ once a week
□ once a month
□ every six months
□ every year
□ every two years or longer
Please check your total, annual family income level:
_____ Less than $10,000
_____ $10,000 - $14,999
_____ $15,000 - $24,999
_____ $25,000 - $34,999
_____ $35,000 - $49,999
_____ $50,000 - $74,999
_____ $75,000 - $99,999
_____ $100,000 - $149,999
_____ $150,000 - $199,999
_____ $200,000 or more
What is the highest level of education you have completed (check one)?
□ never graduated high school
□ high school diploma
□ college
83
□ graduate program
□ doctoral degree
□ professional degree
□ other____________
What is your current relationship status?
□ married
□ partnered
□ separated
□ divorced
□ single
□ other____________
84
Appendix D
Defensive Style Questionnaire-40
Instructions: This questionnaire consists of a number of statements about personal
attitudes. There are no right or wrong answers. Using the 9-point scale shown below,
please indicate how much you agree or disagree with each statement by circling one of
the numbers on the scale beside the statement. For example, a score of 5 would indicate
that you neither agree nor disagree with the statement, a score of 3 that you moderately
disagree, a score of 9 that you strongly agree.
1. I get satisfaction from helping others and if this were taken away from me I would
get depressed.
1
2
3
4
5
6
7
8
9
2. I’m able to keep a problem out of my mind until I have the time to deal with it.
1
2
3
4
5
6
7
8
9
3. I work out my anxiety through doing something constructive and creative like
painting or woodwork.
1
2
3
4
5
6
7
8
9
4. I am able to laugh at myself pretty easily.
1
2
3
4
5
6
8
9
5. I am able to find good reasons for everything I do.
1
2
3
4
5
6
7
8
9
6. People tend to mistreat me.
1
2
3
4
9
5
6
7
7
8
7. If someone mugged me and stole my money, I’d rather he be helped than
punished.
1
2
3
4
5
6
7
8
9
85
8. People say, I tend to ignore unpleasant facts as if they didn’t exist.
1
2
3
4
5
6
7
8
9
9. I ignore danger as if I were superman.
1
2
3
4
5
6
7
8
10. I pride myself on my ability to cut people down to size.
1
2
3
4
5
6
7
8
9
9
11. I often act impulsively when something is bothering me.
1
2
3
4
5
6
7
8
9
12. I get physically ill when things aren’t going well for me.
1
2
3
4
5
6
7
8
9
13. I’m a very inhibited person.
1
2
3
4
5
9
6
7
8
14. I get more satisfaction from my fantasies than from my real life.
1
2
3
4
5
6
7
8
9
15. I’ve special talents that allow me to go through life with no problems.
1
2
3
4
5
6
7
8
9
16. There are always good reasons when things don’t work out for me.
1
2
3
4
5
6
7
8
9
17. I work more things out in my daydreams than in my real life.
1
2
3
4
5
6
7
8
9
18. I fear nothing.
1
2
3
4
5
6
7
8
9
19. Sometimes I think I’m an angel and other times I think I’m a devil.
1
2
3
4
5
6
7
8
9
20. I get openly aggressive when I feel hurt.
1
2
3
4
5
6
7
8
9
21. I always feel that someone I know is like a guardian angel.
1
2
3
4
5
6
7
8
9
86
22. As far as I’m concerned, people are either good or bad.
1
2
3
4
5
6
7
8
9
23. If my boss bugged me, I might make a mistake in my work or work more slowly
so as to get back at him.
1
2
3
4
5
6
7
8
9
24. There is someone I know who can do anything and who is absolutely fair and just.
1
2
3
4
5
6
7
8
9
25. I can keep the lid on my feelings if letting them out would interfere with what I
am doing.
1
2
3
4
5
6
7
8
9
26. I’m usually able to see the funny side of an otherwise painful predicament.
1
2
3
4
5
6
7
8
9
27. I get a headache when I have to do something I don’t like.
1
2
3
4
5
6
7
8
9
28. I often find myself to be nice to people who by all rights I should be angry at.
1
2
3
4
5
6
7
8
9
29. I am sure I get a raw deal from life.
1
2
3
4
5
6
7
8
9
30. When I have to face a difficult situation I try to imagine what it will be like and
plan ways to cope with it.
1
2
3
4
5
6
7
8
9
31. Doctors never really understand what is wrong with me.
1
2
3
4
5
6
7
8
9
32. After I fight for my rights, I tend to apologize for my assertiveness.
1
2
3
4
5
6
7
8
9
33. When I depressed or anxious, eating makes me feel better.
1
2
3
4
5
6
7
8
9
87
34. I’m often told that I don’t show my feelings.
1
2
3
4
5
6
7
8
9
35. If I can predict that I’m going to be sad ahead of time, I can cope better.
1
2
3
4
5
6
7
8
9
36. No matter how much I complain, I never get a satisfactory response.
1
2
3
4
5
6
7
8
9
37. Often I find that I don’t feel anything when the situation would seem to warrant
strong emotions.
1
2
3
4
5
6
7
8
9
38. Sticking to the task at hand keeps me from feeling depressed or anxious.
1
2
3
4
5
6
7
8
9
39. If I were in a crisis, I would seek out another person who had the same problem.
1
2
3
4
5
6
7
8
9
40. If I have an aggressive thought, I feel the need to do something to compensate for
it.
1
2
3
4
5
6
7
8
9
88
Appendix E
Attitudes Toward Seeking Professional Psychological Help-Short Form
Please Circle One of the Following:
1. If I believed I was having a mental breakdown, my first inclination would be
to get help from a mental health professional.
Agree
Partly Agree
Partly Disagree
Disagree
2. The idea of talking about problems with a mental health professional strikes
me as a poor way to get rid of emotional conflicts.
Agree
Partly Agree
Partly Disagree
Disagree
3. If I were experiencing a serious emotional crisis at this point in my life, I
would be confident that I could find relief in psychotherapy.
Agree
Partly Agree
Partly Disagree
Disagree
4. There is something admirable in the attitude of a person who is willing to
cope with his or her conflicts and fears without resorting to professional
psychological help.
Agree
Partly Agree
Partly Disagree
Disagree
5. I would want to get psychological help if I were worried of upset for a long
period of time.
Agree
Partly Agree
Partly Disagree
Disagree
6. I might want to have psychological counseling in the future.
Agree
Partly Agree
Partly Disagree
Disagree
7. A person with an emotional problem is not likely to solve it alone; he or she is
likely to solve it with professional help.
Agree
Partly Agree
Partly Disagree
Disagree
8. Considering the time and expense involved in psychotherapy, it would have
doubtful value for a person like me.
Agree
Partly Agree
Partly Disagree
Disagree
89
9. A person should work on his or her own problems; getting psychological
counseling would be a last resort.
Agree
Partly Agree
Partly Disagree
Disagree
10. Personal and emotional troubles, like many things, tend to work out by
themselves.
Agree
Partly Agree
Partly Disagree
Disagree
90
Appendix F
Health Attitudes Survey
Please Circle One of The Following:
1. I have been satisfied with the medical care that I have received.
Strongly Disagree
Disagree
Neutral
Agree Strongly Agree
2. Doctors have done the best they could to diagnose and treat my health problems.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Agree
Strongly Agree
Agree
Strongly Agree
3. Doctors have taken my health problems seriously.
Strongly Disagree
Disagree
Neutral
4. My health problems have been thoroughly evaluated.
Strongly Disagree
Disagree
Neutral
5. Doctors do not seem to know much about the health problems that I have had.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Agree
Strongly Agree
6. My health problems have been completely explained.
Strongly Disagree
Disagree
Neutral
7. Doctors seem to think I am exaggerating my health problems.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Agree
Strongly Agree
Agree
Strongly Agree
8. My response to treatment has not been satisfactory.
Strongly Disagree
Disagree
Neutral
9. My response to treatment is usually excellent.
Strongly Disagree
Disagree
Neutral
10. I am tired of feeling sick and would like to get to the bottom of my health problems.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Neutral
Agree
Strongly Agree
11. I have felt ill for quite a while now.
Strongly Disagree
Disagree
91
12. I am going to keep searching for an answer to my health problems.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
13. I do not think there is anything seriously wrong with my body.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Agree
Strongly Agree
Neutral
Agree
Strongly Agree
Neutral
Agree
Strongly Agree
Agree
Strongly Agree
Agree
Strongly Agree
Agree
Strongly Agree
Agree
Strongly Agree
14. I have seen many different doctors over the years.
Strongly Disagree
Disagree
Neutral
15. I have taken a lot of medicine recently.
Strongly Disagree
Disagree
16. I do not go to the doctor often.
Strongly Disagree
Disagree
17. I have had relatively good health over the years.
Strongly Disagree
Disagree
Neutral
18. I sometimes worry too much about my health.
Strongly Disagree
Disagree
Neutral
19. I often fear the worst when I develop symptoms.
Strongly Disagree
Disagree
Neutral
20. I have trouble getting my mind off my health.
Strongly Disagree
Disagree
Neutral
21. Sometimes I feel depressed and cannot seem to shake it off.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
22. I have sought health for emotional and stress related problems.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Neutral
Agree
Strongly Agree
23. It is easy to relax and stay calm.
Strongly Disagree
Disagree
24. I believe the stress I am under may be affecting my health.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
92
25. Some people think that I am capable of more work than I feel able to do.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
26. Some people think that I have been sick just to gain attention.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
27. It is difficult for me to find the right words for my feelings.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree