When I was in training, I was cautioned to be wary of patients who presented for a neuropsychological evaluation with a list of symptoms and possible diagnoses. In this age of cyberchondria, it is not uncommon that medical consumers appear at the clinician's doorstep having researched their symptoms on the internet, possibly even arriving with a homemade differential diagnosis before coming to medical attention. This degree of attention to symptoms is often associated with psychological distress, which may or may not be at the root of the symptoms. It stands to reason that the presence of a medical disorder, especially one that is difficult to diagnose, does not exclude, but probably increases the likelihood of psychological distress. The presence of symptoms with no medical explanation may be explained by somatization, yet not all medically unexplained symptoms are suggestive of somatization. This false dichotomy is at the root of the controversy surrounding the various inadequacies of the diagnostic classification of somatic syndromes.
As suggested by the title, Understanding Somatization in the Practice of Clinical Neuropsychology, this volume offers insight for neuropsychologists confronted with what is arguably the most challenging patient population. The purpose of this book is to provide practitioners with the conceptual understanding and clinical tools needed to identify, assess, and appropriately refer patients with medically unexplained symptoms.
Clinical neuropsychology is not an exact science; there is art to its practice, which involves use of one's clinical intuition derived from the internal database of patients evaluated over the years. The author expresses his desire to combine “artful” understanding of patients with medically unexplained symptoms. He suggests that rather than being frustrated by the challenges in evaluating patients with unexplained medical symptoms, neuropsychologists, by virtue of their unique assessment skills, may be the most appropriate practitioner to rise to the challenge of diagnosing, educating, or intervening with this population. Cognitive complaints in patients who present for a neuropsychological evaluation may be observed in conjunction with a variety of medical conditions, regardless of the presence of direct central nervous system involvement. Neuropsychologists need to be skilled in assessing the relationship between subjective concerns and objective cognitive dysfunction.
The author was a long time member of the Board of Directors of the American Academy of Clinical Neuropsychology (AACN), was Program Chair for the AACN Annual Meeting and Workshops from its inception in 2003 until 2007, and currently serves as President. This volume is the third in a series of publications derived from AACN workshops. The book contains information for online access to the original workshop presentation's PowerPoint slides, which from the look of the slides suggests attendees got their money's worth. The reader can also obtain continuing education credits online.
The book begins with a convincing argument that recognizes how somatization is regarded by many as a nuisance variable, one that inevitably leads to the “end of the neuropsychological story,” but how gaining improved understanding of these disorders can lead to improved diagnostic acumen. What follows is a discussion of the evolution and controversy surrounding the diagnostic classifications of somatoform disorders in various versions of the Diagnostic and Statistical Manual of Mental Disorders as well as International Classification of Diseases (e.g., ICD-9). This historical perspective provides a context for current diagnostic classifications of somatic disorders, as well the origin of the biases practitioners may have in evaluating and treating these patients.
Challenges of the available diagnostic classification schemas for both clinicians and researchers are addressed. Despite the belief that most psychological diagnoses have a presumed biologic underpinning, patients with somatization present with symptoms that do not have a direct medical explanation. Suggestions are made for a new diagnostic approach, one that considers the strong link between mind and body, so disorders need not necessarily be classified as pertaining to either one or the other. Here, the mind-body connection is re-emphasized along with the biological orientation of modern day psychiatry. Developmental, theoretical, and cultural viewpoints are explored in terms of how they relate to understanding the nature of somatization and somatoform disorders. The emergence of the term “medically unexplained symptoms” is addressed, as are functional somatic symptoms such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome, which are differentiated from somatoform disorders in that patients attribute symptoms to a specific cause. These diagnoses provide the context of a medical diagnosis for emotional distress experienced by patients who would be resistant to a strictly psychological interpretation of their condition.
Various treatment strategies are explored, but our treatment expectations are managed by pointing out that although therapies such as Cognitive Behavior Therapy can be effective for patients with somatization or somatic syndromes, the resultant benefits can and probably will occur despite little or no change in psychological distress. Given that patients are invested in physical complaints and medical explanations, they are unlikely to acknowledge improvement in psychological symptoms following treatment.
A distinct strength of this book has to do with the delivery of the material; it is especially thoughtful and does not try to sell one particular theory or approach. Rather, one can gain historical perspective on the origin of the diagnostic classification as well as the value of providing feedback to the somaticizing patient. The perspective of this book is to rid the clinician of potential biases regarding the somaticizing patient and to promote understanding of the mind-body connection as part of the diagnostic challenge. The result is a more positive view of the human condition—a perceptive insightful approach to patients with complex medical diagnoses who present in clinical neuropsychological practice. It discourages making the false choice of deciding in a dichotomous manner whether symptoms originate from an underlying medical condition or are a result of health anxiety or some other form of psychological distress. Although all points are supported by relevant references to published studies, the book is more of a well-written exposition than a review of the literature. The author has been able to create a work of interest to clinicians looking to gain a new perspective on difficult to diagnose patients, yet, it is scholarly enough to highly recommend this volume to trainees seeking to further understand the relationship between brain and behavior. Since it seems unlikely that one would never encounter the influence of somatization in a clinical setting, this book would be of value to all practicing clinicians.
