Questions and Answers
Does somatization mean “imaginary” symptoms?
A symptom is something reported by a person to a doctor. In somatization, it is by no means imaginary. This does not mean that there is necessarily something wrong in the area where the person believes the problem is located (for example, the intestines, stomach, or neck); the symptom nevertheless exists (cramp, sensation of bloating, a “lump,” stiffness, etc.).
The term “somatoform” therefore refers to a symptom or sign that is not imaginary, but that does not correspond to a problem originating in the area to which the symptom is attributed. Instead, it originates in the nervous system.
A “sign,” on the other hand, is something measured or observed by the doctor, and therefore it may or may not actually be present. For example, a person may feel their heart “in their throat” while the heart is beating normally, or feel that their breathing is “not getting through” even though there is no obstruction. Thus, saying “my legs feel stiff” when the legs are not actually stiff does not mean that the person has made it up. There is simply a symptom (the sensation of stiffness in the legs) that does not correspond to a physical sign (stiff muscles).
Does the doctor “not believe me,” or am I unable to make myself understood?
Often, after various possibilities have been investigated and “nothing” has been found, somatoform symptoms are dismissed with statements such as “there is nothing wrong with you” or “it’s anxiety.”
If the mechanism of somatization is not explained to the patient, however, they may remain convinced that their symptoms were not genuinely believed and that they were attributed to some kind of fake behavior, as though they were an “imaginary invalid.”
Sometimes, on the other hand, it is the patient who wants to find “something” wrong. Faced with a diagnosis of somatization, they may therefore feel that they have received a superficial assessment and that they were not believed simply because the doctors did not understand where to investigate.
“Organic” or “psychogenic” symptom: what does it mean?
Another, more technical, expression is: “There is nothing organic, so it is psychogenic.”
“Organic” would essentially mean something that can be seen or identified physically, even microscopically. “Functional,” on the other hand, refers to something that may not be visible on an examination but can nevertheless be measured through a parameter or numerical value.
“Psychogenic” could mean that a symptom is reported even though there is no corresponding physical abnormality (so the person behaves abnormally by reporting symptoms they do not actually have). Alternatively, it can mean that the symptom is reported according to how the person experiences it — amplified, misinterpreted, or accompanied by worry — but cannot be objectively measured, or the objective measurement does not correspond to the reported intensity.
“Somatization” means that the disorder has been recognized as originating from the nervous system in a functional manner, not merely because everything else has been ruled out, but because a psychological correspondence has been identified. The sensations are genuine and can be intense, but the mechanism originates in the central nervous system and is often associated with anxiety or depression.
“Hypochondria,” on the other hand, is another functional (psychological) disorder that leads a person to report, with excessive concern, bodily problems that do not actually exist but that take shape in the person’s thoughts.
There is also a third, rarer possibility, in which a person reports symptoms that do not exist while knowing this, or deliberately produces them: this is factitious disorder, which is obviously different from somatization.
Can worry create “imaginary” symptoms?
Hypochondria is a condition characterized by concern about having a physical problem, whether obvious or hidden.
Often, the person is unable to distinguish between a normal bodily sensation and a “symptom,” because everything becomes a “symptom” when combined with worry, from a minor pain to an itch that comes and goes.
In other words, common bodily signals or common illnesses become such a source of concern that they are reported in great detail, with an insistence on their severity that simply reflects the severity of the worry.
The patient usually tends to give a very detailed description, in which the seriousness of the problem is paradoxically supposed to emerge from the detail, specificity, or unusual nature of the symptom, rather than being immediately apparent from the overall presentation.
A serious symptom generally does not require extensive explanation or description. By contrast, the symptoms reported by a person with hypochondria are often intense worries about things that do not even correspond to symptoms, but simply to bodily sensations or situations that would normally be ignored or not registered as alarming.
Is anxiety what causes somatization?
Patients do not always understand exactly how anxiety “causes” somatization, largely because this is not quite what happens: anxiety and somatization occur together and are both produced by a particular state of the nervous system.
Saying that bodily symptoms are an anxiety problem can mean two things: either that anxiety is accompanied by increased awareness of bodily signals, even when they do not correspond to any objective problem; or that when the person is anxious, they become worried that something is wrong with them, and bodily signals therefore trigger or reinforce hypochondriacal concerns.
Are people depressed because of somatization, or do they experience somatization because they are depressed?
Many patients who present with concern about a symptom, in the context of hypochondria, believe that the mechanism underlying their distress works as follows: they have a symptom, it is unclear what is causing it or how to resolve it, and therefore they inevitably become fixated on it and become demoralized.
In reality, in hypochondria the situation is the opposite: worry is followed by demoralization, based on what is feared, and by the fact that the thought that something is wrong, or the attention directed toward the body, becomes amplified and takes center stage in the person’s thinking. The symptom itself then becomes something consequential: it is not the cause, but the consequence.
Furthermore, during depression, worried attention toward the body typically increases. The person amplifies their symptoms or their consequences, anticipates disastrous developments, and mentally prepares themselves for having to adapt to limitations or irreversible damage.
How many medical tests should be performed to rule out 100% of all other possible causes?
One of the dead ends for a patient with somatization is undergoing “endless” medical tests.
Medical investigations are intended to verify hypotheses formulated by the doctor. Investigations requested on the basis of non-technical “impressions” — casual reading, hearsay analogies, the patient’s own assumptions, or fears about particular diseases — can instead disrupt the doctor-patient relationship.
The investigation becomes a reassuring response, but in reality it is inconclusive because it does not provide definitive, clear, or constructive answers.
A large proportion of patients who undergo investigations because of vague or nonspecific symptoms receive reports that mention an equally vague “component” that nevertheless does not explain either the intensity or the course of the symptom.
Moreover, investigations performed at random often end up finding something that is common in the general population — osteoarthritis, hiatal hernias, mild gastritis, etc. — which “could” explain some symptoms but in reality provides no clear conclusion.
The best approach to medical investigations is always to carry them out on the basis of a medical opinion, whether from a primary-care doctor or a specialist.
A diagnosis of somatization disorder or hypochondria is not made simply by exclusion. It is based primarily on the presence of the characteristic psychological symptoms of these conditions.
If the concern persists even after a diagnosis of somatization, the person has probably not understood that the diagnosis is not merely one of exclusion and does not amount to labeling them as “imagining things” or judging them to be exaggerating because they are anxious. Rather, it is a diagnosis of a psychological condition that also manifests itself through bodily symptoms or concern about the body.
Returning to the concept of a diagnosis by exclusion, in general no medical investigation can provide absolute certainty. The need for absolute certainty is a mental need that arises from uncontrolled worry — a type of worry that is not satisfied with a diagnosis and wants to “see,” with certainty, some reassuring but undefined answer.
From this perspective, only the worst possible diagnoses would be convincing. Indeed, a person with hypochondria is, in a sense, suspended between the terror of having a serious illness and the desire to eliminate every reasonable doubt that they might have it.
Since the doubt is not actually reasonable, they remain trapped in this suspended state.
By definition, no certainty can exist when an investigation is performed in order to eliminate an obsession or fear rather than to test a specific hypothesis.
Is reassurance important?
Reassuring a patient who is obsessed with a hypochondriacal thought is usually not helpful, except temporarily, when it may reduce anxiety.
The problem is that this sense of urgency tends to return whenever the hypochondriacal thought returns. Reassurance then has to rely on other tools, such as medical tests, in order to be convincing, creating a vicious circle.
Eventually, either the patient will “demand” reassurance, perhaps even telling the doctor what could be done to make the answers more convincing, or the doctor will no longer know how to provide reassurance in a convincing way.
Both situations are dead ends for the patient and the doctor, who lose the basis of their therapeutic relationship.
In hypochondria, as far as possible, fear should not be the basis for medical investigations or for discussions about the merits of particular medical hypotheses. If anything, fear can be the basis for discussing the fear itself, its mechanisms, and its meaning.
Reassurance in a state of hypochondriacal obsession, on the other hand, risks sending the brain a message that the fear itself is well-founded, or that reassurance is important and must be sufficiently convincing.
Does checking one’s body and bodily functions help reduce anxiety?
Usually not.
There are techniques that instead teach people to create mental representations of bodily functions in ways that prevent states of alarm from turning them into sources of somatization or hypochondriacal concern.
Checking one’s bodily functions in order to “understand” whether they are functioning properly is a snake biting its own tail: the person who checks will always think that they have not checked enough, or that the signals are too confusing to be interpreted reliably.
Eventually, attention becomes focused on the external bodily area, or on the mental image of that bodily area as it emerges together with the worry. The person then tends to lose sight of their behaviors and psychological symptoms as the central focus of the problem.