Psychosomatics 40:34-43, February 1999
© 1999 The Academy of Psychosomatic Medine
Attachment and Interpersonal Communication in Somatization
Scott Stuart, M.D., and
Russell Noyes, Jr., M.D.
Received August 3, 1998; accepted August 20, 1998. From the Department of Psychiatry, University of Iowa, Iowa City. Address correspondence and reprint requests to Dr. Stuart, University of Iowa, Department of Psychiatry, 200 Hawkins Drive, Iowa City, IA 52242. E-mail: scott-stuart{at}uiowa.edu
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ABSTRACT
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The authors review the research on childhood antecedents and personality contributions to the somatoform disorders, as well as research on social influences during adulthood. Based on these data, the authors hypothesize that somatizing patients display anxious attachment behavior that derives from childhood experiences with caregivers. Early exposure to illness increases the likelihood that distress will be manifested somatically. When under stress as adults, somatizers use physical complaints to elicit care. Somatizers' interpersonal interactions with others, including physicians, ultimately lead to rejection that reinforces the somatizer's belief that he or she will be abandoned. Modification of physicians' responses to these patients may improve treatment outcomes.
Key Words: Attachment • Communication • Somatization
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INTRODUCTION
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The costly and time-consuming treatment of patients with somatoform disorders has recently been described as a "crisis" in medical care.1 The prevalence of the disorder in primary care settings has been estimated to be as high as 25%,2 and it is estimated that from 30% to 60% of primary care patients complain of symptoms that have no medical basis. The broad category of somatization includes the somatoform disorders described in DSM-IV:3 somatization disorder, pain disorder, hypochondriasis, conversion disorder, and undifferentiated somatoform disorder. All are characterized by physical symptoms that are not explained by medical conditions, and all are associated with substantial distress and impairment.
Somatizing patients often complain of pain, gastrointestinal, sexual, and pseudo-neurological symptoms. These patients tend to be vague historians, but their presentations are often dramatic and they often have extensive and complicated medical histories. Such patients are persistent in their pursuit of medical care, moving abruptly from one doctor to another, or consulting a number of physicians concurrently. These patients' lives are often chaotic, and their histories often include impulsive or manipulative behavior, suicide threats or attempts, marital discord, and conflictual interpersonal relationships.
The somatoform disorders are associated with significant physical distress andimpairment in occupational and social functioning. They are associated with increases in work absences and time spent in bed, and with a lower life satisfaction.4 Additionally, somatizing patients overuse medical services, including more outpatient visits, referrals to specialists, unneeded medical tests, and more unwarranted use of medications than other medical patients.5 Such patients spend more days in the hospital than nonsomatizing patients, and are at increased risk for iatrogenic injury.5
A number of theories have been proposed to explain the genesis of somatization, and two models have attracted attention as leading hypotheses. According to the first, adverse childhood experiences contribute to the development of somatizing behavior. Childhood exposure to models of illness behavior, such as a parent with chronic illness, may increase the risk for somatization. Additionally, exposure to trauma, such as physical or sexual abuse, may also predispose persons to respond to stress somatically. These experiences may contribute directly to somatizing behavior or may contribute indirectly by influencing personality development.
According to the second model, somatizing behavior is a manifestation of maladaptivecommunication of distress in response to environmental stress. Illness behavior elicits caregiving responses from others and may direct attention away from other areas of conflict. The interpersonal environment in which the somatizing behavior occurs includes the family, in whicha patient's physical symptoms may be a manifestation of familial dysfunction, and the medical community, in which physicians' negative reactions to patients with multiple physical complaints may increase somatizing behavior. Cultural attitudes that emphasize medical diagnoses and treatment, and patients' demands for a definitive "cure," may contribute as well.
We hypothesize that adverse childhood experiences have a profound impact on the development of the attachment styles of persons who later manifest somatizing behavior. A pattern of insecure attachment develops that is later reflected in personality traits and interpersonal behaviors (such as persistent care-seeking behavior) that are maintained throughout adulthood. During times of stress, these maladaptive personality traits and inflexible care-seeking behaviors result in interpersonal interactions that culminate in rejection by spouses, family members, and health care professionals. This pattern of self-defeating interpersonal interaction creates a descending spiral in which the somatizer's maladaptive care-seeking behavior provokes hostility in others, further exacerbating his or her care-demanding behavior.
We review the research on the childhood antecedents of somatization and the literature on the role of the family and physicians in its genesis and perpetuation. We also draw upon attachment and interpersonal theory in proposing a comprehensive model for the development of somatization.
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EARLY LIFE EXPERIENCES AND SOMATIZATION
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Childhood Illness
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There is a large body of research on the influence of childhood illness on the development of somatizing behavior. For instance, Craig et al.6 found that adult somatizers reported more frequent and serious childhood illnesses than other psychiatric and medical patients. About 20% of the somatizing patients studied by Bass and Murphy7 reported having a chronic disabling illness before age 16. Hypochondriacal patients also reported having been sick more often as children and having missed more school than did the control subjects from a medical clinic.8 Conversely, reports of serious childhood illness among medical inpatients were highly correlated with hypochondriacal symptoms.9 In addition, Pilowsky et al.10 found that chronic pain patients were more likely to have been hospitalized as children.
There is also evidence that parental responses to childhood illness are associated with somatizing behavior. Children's reactions to pain tend to mirror those of their parents11 and are often governed more by the affective responses of their parents than by the trauma itself. For example, a child who injures him- or herself may not react until he or she has gauged his or her parents' response (e.g., attention, concern, or inattention). Patients with somatization disorder report that their parents practiced more selective caretaking during childhood illnesses compared with control subjects.12,13 Violon14 has coined the term "conditional caretaking" to describe the selective attention paid by parents to their children's physical complaints while ignoring their emotional needs. This type of parental response may reinforce illness behavior during childhood, which then becomes maladaptive in adulthood.
Inadequate or inattentive parenting may also contribute to the genesis of somatizing behavior in adults. Mallouh et al.15 found that inpatients with somatization disorder were characterized by a loss experience during early childhood, usually the loss of a parent or caretaking figure. The patients with such histories typically had more conflictual interpersonal relationships as well. The patients with somatization disorder also reported having received less maternal care than the patients with other psychiatric disorders.6 Bass and Murphy found that long-term disability that interfered with a parent's ability to provide care had occurred in about half of their patients with somatization disorder.7 These patients also reported receiving less maternal care than the matched control subjects with other forms of mental illness. Punitive attitudes and rejection have also been observed in the parents of patients with somatization disorder.14
According to Craig et al.,6 somatization is best modeled by a combination of inadequate parental care and childhood illness. They state that "among somatizers, childhood illness afforded an escape from neglect and abuse, or encouraged some badly needed attention from a withdrawn or indifferent parent, and thus set in motion a pattern of care-eliciting behavior that was to be repeated later in life." They further hypothesize that lack of parental care may predispose persons to psychopathology during times of stress, while childhood exposure to illness and illness behavior may lead to somatization as an expression of distress.
It is not clear, because of the retrospective nature of the research, whether somatizing patients are truly exposed to adverse early environments or are merely biased in their reporting. It is also not clear to what extent genetically determined temperamental patterns evoke negative caregiving responses from parents. Nonetheless, the link between early environment and somatizing behavior in adulthood deserves further study.
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Parental Illness
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Social learning, or modeling of illness behavior, also influences the behavior of children. Children exposed to their parents' maladaptive illness behavior adopt the responses to pain and illness that they observe. According to Craig,16 observing the consequences of another's behavior may inhibit or reinforce that of a child by signifying which patterns of illness behavior are appropriate and likely to be reinforced, and which are socially unacceptable and likely to be punished. Simply put, children exposed to parents who deal with pain and illness adaptively will adopt similar behavioral strategies; children exposed to exaggerated responses to illness are likely to exhibit similar behaviors when the children observe the social rewards reaped by their parents.
There is a substantial literature supporting the influence of social modeling on illness behavior. Bass and Murphy7 noted that over half of their patients with somatization disorder had been exposed to physical disability in one or both parents. Craig et al.6 also found that patients with somatization disorder frequently had parents who experienced physical illness. The effects of social modeling may be apparent before adulthood; for instance, Morgan et al.17 noted that, among adolescents from a psychiatric clinic, those with physically ill parents had more somatic symptoms.
Similar findings were reported by Jamison and Walker,18 who studied children of adults with chronic pain. The researchers found that high levels of somatic symptoms in these children were associated with disability and pain behavior in their parents. Additionally, Jamison and Walker noted that children of parents with chronic pain reported more abdominal pain and used more pain medication. Children of parents with severe and chronic headaches also exhibited more pain behavior and somatic preoccupation.19 Similarly, psychogenic chest pain was more frequent in children with family histories of chest pain,20 and recurrent abdominal pain was more frequent in children with a family history of abdominal pain.11 Conversely, the children with recurrent abdominal pain were more likely to have parents with somatization disorder than were the control children.21
Although the evidence supports the importance of parental modeling of illness behavior, dysfunctional parenting may be more influential in the development of somatizing behavior. Poor or inadequate parenting is undoubtedly confounded by chronic parental illness, which may render parents unavailable to their children both physically and emotionally. Moreover, the family system may be disrupted by chronic illness, and this broader problem may account for the development of somatizing behavior.
Parents of children with somatoform disorders have also been found to have a high prevalence of mental disorders. Volkmar et al.22 noted that 44% of their patients with somatization disorder had a family history of mental disorder, compared with 27% of the control subjects with adjustment reactions. Similarly, Goodyer23 reported that 73% of somatizers had immediate family members with psychiatric disorders. In addition, Routh and Ernst21 found that a higher proportion of the children with functional abdominal pain had relatives with alcoholism, antisocial personality, conduct disorders, or attention deficit disorders than did the children with organic abdominal pain.
Early studies of Briquet's syndrome found that the disorder clustered in the families of patients with both somatization disorder and antisocial personality disorder.24,25 It is not clear how important genetic influences are in the development of somatization, as familial aggregation may result from genetic factors, "pathological" parenting, or a combination of the two. Twin studies do not appear to support a high degree of genetic transmission,26,27 and most authors favor a combination of genetic and environmental influences, noting that genetic factors may contribute primarily to predisposing personality traits.28
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Childhood Trauma
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Traumatic experiences during childhood may also contribute to somatizing behavior. The notion that somatic symptoms might be the sequelae of traumatic experiences has a long history in psychiatry, and was first proposed by Freud.29 More recently, Morrison30 found unwanted childhood sexual contact in 55% of women with somatization disorder, compared with 16% of women with affective disorders. Similarly, Coryell and Norton31 found a higher rate of sexual abuse in the patients with somatization disorder than in the patients with affective disorders, and Pribor and Dinwiddie32 reported a high rate of somatization disorder (14%) among women who were incest survivors. Additionally, Barsky et al.8 reported that 29% of the patients with hypochondriasis had traumatic sexual contact during childhood, compared with 7% of the control subjects. The women with chronic pelvic pain more frequently report sexual abuse,33 and the women with histories of abuse report more somatic symptoms, including pelvic pain.34,35
Walling et al.,36 however, did not find that childhood sexual abuse predicted somatization disorder when childhood physical abuse was considered, and the researchers criticized other studies for not considering this confounding variable. Likewise, Morrison30 initially found that the women with somatization disorder were more likely to report childhood sexual abuse than the women with primary affective disorders. Later evaluation, however, demonstrated that this difference was better accounted for by a chaotic family environment.37 Thus, when other factors are considered, the specific effects of sexual abuse become less clear. Additionally, the majority of women with somatization disorder do not report sexual abuse, suggesting that, by itself, this factor has limited importance.
Physical abuse has also been linked to somatization disorder. Walling et al.36 found that, among all early traumatic experiences, childhood physical abuse was the best predictor of somatization disorder. Adult physical abuse was also a significant predictor. Barsky et al.8 reported that 32% of the patients with hypochondriasis had been exposed to physical violence during childhood, compared with 7% of the medical clinic control subjects.
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Personality and Somatization
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Somatizing behavior may be a manifestation of personality pathology. Early descriptions of hysteria, for example, included histrionic personality traits. However, in an effort to develop verifiable criteria and eliminate personality features from Axis I disorders, references to abnormal illness behavior were dropped from the somatization disorder criteria in DSM-III.38 Yet observers commonly regard personality dysfunction as an important, even essential, feature of the somatoform syndromes. For example, over half of the British psychiatrists surveyed viewed somatization disorder as both a personality and a "mental state" disorder.39 According to Kaminsky and Slavney,40 what characterizes somatizing patients is not the number or severity of their medically unexplained symptoms, but the patient's dramatic and persistent complaints about them.
Clinical research has consistently demonstrated a relationship between personality disorders and Briquet's syndrome or somatization disorder. Based on family data, early investigators proposed that somatization disorder and antisocial personality disorder might be gender-linked expressions of a common hereditary diathesis.41 However, studies supporting this hypothesis focused exclusively on the personality disorders of interest, neglecting other Axis II pathology. Additionally, treatment-seeking behavior and referral biases may have influenced the findings.
In contrast, studies examining the full range of personality disorders have found nonspecific increases in patients with somatoform disorders. For example, in the somatizing patients referred from primary care settings, Rost et al.42 identified personality disorders in 61% of the patients. The most frequent disorders were avoidant, paranoid, self-defeating, and obsessive–compulsive. Histrionic personality disorder was observed in only 13% of the patients, and antisocial personality disorder in only 7%. A similar nonspecific increase was found in a British study of medical clinic patients with somatization disorder.43 Personality disorders were diagnosed in 72% of these patients, compared with 36% of the control subjects. Those with somatization disorder had more severe personality disorders, and many met criteria for more than one disorder. The most common were passive-dependent, histrionic, and sensitive-aggressive. Borderline personality disorder is also common in somatizing patients.44 Similar findings were obtained from a study of patients referred to a behavioral medicine clinic, where Emerson et al.45 identified personality disorders in 63% of the patients with somatoform disorders, compared with 44% of the depressed and 41% of the anxious patients. The researchers did not find any specific personality disorder to be more common among the somatizing patients.
Kirmayer et al.46 caution that most research on somatoform disorders confounds the mechanisms of symptom production with factors that influence help-seeking behavior. Thus, clinical samples may not be representative of the disorder because they are biased toward persons seeking treatment. In consideration of this, Kirmayer et al. urged that community studies be undertaken to examine these processes separately. A variety of personality dimensions, including neuroticism, harm avoidance, and negative affectivity, influence reporting of both somatic and psychological symptoms and may contribute to somatization.47 Likewise, traits that heighten somatic perception or increase self-absorption may contribute to symptom reporting.
Other personality traits may contribute to conflictual or unsatisfactory interactions with health care providers. Difficult somatizing patients have been described as angry, resentful, and mistrustful.46 Wetzel et al.48 found that women with Briquet's syndrome had Minnesota Multiphasic Personality Inventory scores more indicative of interpersonal alienation and interpersonal problems than did women with depression. The Briquet's patients scored higher on scales reflecting distance, discord, problems with intimacy, and poor behavioral control. Personality traits that lead to conflict with medical care providers may also contribute to psychiatric referral and, consequently, to an overrepresentation of persons with conflict-prone personality characteristics in psychiatric populations.
The literature is unclear as to whether personality disorders predispose patients to the development of somatizing behavior, or whether maladaptive personality traits develop as a result of patients' attempts to deal with chronic illness. It seems likely that personality characteristics serve as a diathesis for maladaptive care-seeking behaviors. The chronic nature of somatization may, in turn, reinforce such personality characteristics over time. Longitudinal studies are needed to clarify this issue.
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SOCIAL FACTORS AND SOMATIZATION
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Family Influences
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In contrast to the physiologic conceptualization of pain as a discrete and reproducible neurological phenomenon, the expression of pain is, in large part, determined by the social context in which it occurs. A person experiencing pain may turn to his or her interpersonal environment for validation of suffering, or may seek social recognition for a painful experience. This validation (or lack thereof) affects the person's communication of pain, which in turn influences the responses of caregivers within his or her social system. Thus, the social structure affects, and is affected by, a person's communication of pain.
According to family systems theorists, somatization permits the family to focus attention on illness behavior while drawing attention away from other conflicts.49 Marital conflict has frequently been reported in the families of somatizing patients,49,50 and such families have been found to be less supportive, cohesive, and adaptable than the control families.51,52 The literature is replete with reports of families in which functional symptoms in children or adults mask the "real" conflict.
The family system may also influence the development of coping styles during childhood. Bass and Murphy7 have likened abnormal illness behavior to a personality disorder and hypothesize that children develop chronic physical symptoms in reaction to their family environment. Somatizing behavior may evolve from strategies developed in childhood to cope with family conflict. During childhood, these strategies may be adaptive, but when they persist into adulthood and are used in diverse social environments, they become problematic. As noted earlier, behaviors arising from childhood experiences may be powerfully reinforced by family members or the family system.
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Influence of the Health Care System
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Although modern medicine no longer accepts as truth the notion that "body" and "soul" commune in the pineal gland, Descartes' ideas about the dualism of mind and body continue to flourish,53 finding expression in the biological models of disease that are prevalent in medicine. The term "somatization disorder," for instance, reflects Descartes' hypothesis—that is, that one can distinguish between "physical" illness and illness of the "mind." The DSM-IV criteria for somatization disorder retain this distinction, explicitly requiring physicians to make a judgment about whether the condition is "real"—meaning "physiologically based"—or "psychosomatic."
Mental health practitioners have supported this mind–body dualism in their conceptualization of the somatoform disorders. The term "somatization" was first used by psychoanalytic writers to describe a process in which unconscious defenses block the experience of anxiety and force its indirect expression in the form of physical symptoms. More recent definitions of somatization continue to regard the phenomenon in a similar manner. Lipowski, for example, describes somatization as "the tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them."54
Conflict between physician and patient occurs when there is a dispute about the legitimacy of the patient's physical disease, and whether he or she is entitled to the "sick" role. The sick role, according to Parsons,55 is intended to protect society from the potentially disruptive effects of illness. It is a temporary role in which the ill person is granted certain privileges but, at the same time, assumes certain obligations. A person assigned the sick role must want to get well, and must seek and cooperate with treatment. He or she is, in return, not blamed for being ill and is granted exemption from his or her usual responsibilities. The authority to assign the sick role resides with the physician, who bases the decision on the evidence of physical disease derived from physical examination and laboratory testing.
By definition, the somatoform disorders require that physicians withhold the sick role, as the diagnoses require an absence of physical findings. Labeling the illness as mental or psychiatric, rather than as a "legitimate" physical illness, creates conflict between patient and physician. The somatizing patient, to justify assumption of the sick role, adamantly demands a medical diagnosis. The physician, meanwhile, typically feels that his or her authority and competence are being challenged. This meeting of irresistible force and immovable object escalates, until the conflict forces dissolution of the relationship, most frequently with the physician feeling frustrated and the patient seeking care elsewhere.
The degree to which somatizing behavior occurs in a given patient–physician interaction is heavily influenced by the physician's attitudes, behaviors, and responses. Physicians who order unnecessary medical investigations or recommend unneeded procedures may reinforce a patient's conviction that there is something "medically" wrong. Uncertainty of diagnosis, inadequate or excessive medical advice, or excessive reassurance may all contribute to the patient's beliefs.1
The attitudes and characteristics of somatizing patients also contribute to conflict with physicians. Difficult, frustrating, and problematic patients frequently have vague presenting complaints, high utilization of services, lack of response to treatment, excessive demands, chronic complaining, and lack of cooperation with treatment.56 According to Schwenk et al.,57 physician perception of patient difficulty is related to medical uncertainty about vague, difficult-to-describe, or undifferentiated problems, and interpersonal difficulties are related to the patient's abrasive style. Walker et al.58 found that patients' preoccupation with unexplained symptoms and perceived lack of control over illness also contributed to physician frustration. Schwenk et al.57 observed that difficulties in the treatment relationship often arose from the interaction between these patient characteristics and physicians' desire to help people and solve problems.
Both Lin et al.59 and Hahn et al.60 found personality disorders overrepresented among difficult and frustrating patients. Hahn et al.60 identified personality disorders in 90% of their difficult vs. 39% of their nondifficult cases. The researchers describe the typical difficult patient as having three or four unexplained symptoms and mild-to-moderate depression along with a moderately abrasive personality. In a second study, Hahn et al.61 found 15% of the medical outpatients difficult for physicians to tolerate. Difficulty in this sample was strongly associated with the number of unexplained symptoms, number of mental disorders, and the presence of somatoform or alcohol abuse disorders.
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Attachment and Interpersonal Theory
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Based on our review of this diverse literature, we theorize that somatizing behavior results from a complex interaction between childhood experiences of illness and the responses of a person's social system to his or her adult illness behavior. Early life experiences, such as childhood illness or physical abuse, serve as diatheses, influencing illness behavior and leading to the development of maladaptive personality traits. Interpersonal stresses in adulthood serve to generate somatizing behavior in vulnerable persons. The point of convergence in this stress-diathesis model is the interpersonal context of somatizing behavior, as communications about suffering have interpersonal meaning.
We further propose that the illness behavior displayed by somatizing patients can be best understood in terms of attachment behavior and interpersonal theory. Attachment is intimately involved in seeking care and is a pattern of behavior designed to evoke responses from others that give comfort and a sense of security. Anxious or insecure attachment promotes more intense care-seeking behavior. The interpersonal responses to a person's illness behavior, both from significant others and from medical professionals, then serve to either allay the person's fear that care will not be forthcoming or further inflate his or her anxiety and care-seeking behavior.
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Attachment and Somatization
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Attachment behavior is designed to attain or retain proximity to another person, usually for the purpose of receiving care.62 Adult attachment behavior is influenced by temperamental and environmental influences, particularly early life experiences with primary attachment figures.62,63 Healthy interpersonal relationships are characterized by flexible attachments, within which persons may serve as either caregivers or care receivers depending on social circumstances. Persons with dysfunctional or anxious attachment styles, on the other hand, behave in ways that are fixed and inflexible. They are more sensitive to perceived or real threats, and persistently attempt to elicit care from others.
When care-seeking in the form of illness behavior is reinforced, it is more likely to continue or recur. Experiences with chronic illness, particularly during childhood, foster the development of illness behavior, and persons maintain that behavior over an extended period of time. In contrast to acute pain, chronic pain requires that the person and significant others establish and maintain many illness-related behaviors. Persons learn maladaptive methods of satisfying their attachment needs this way.
Interactions of this kind influence the development of internal constructs of self and others. Illness-related experiences of the child coalesce over time and are organized into what Bowlby has called "working models."64 These models allow the child to internally simulate his or her behavior and that of others so that the outcome of the behavior can be reliably predicted. The child can thereby anticipate the consequences of his or her behavior and the responses of others by imposing these models on all interpersonal interactions.
The working models that develop in patients with somatoform disorders are influenced by childhood experiences of illness. Chronic illness may erode the child's sense of self-efficacy and bodily integrity, creating a model of self as one who requires care. Lack of parental care during illness or abuse during childhood may undermine self-esteem and contribute to a working model of self as undeserving of care. Working models of significant others are likely to be even more profoundly affected by parental responses to illness. For example, selective attention to a child's illness behavior and inattention to other forms of care-seeking or attachment behavior may lead to a working model in which the child believes that care will be provided only when sought for physical suffering.
Children exposed to this type of environment learn to use expressions of physical pain to convey emotional distress. As adults they use language to which they have become accustomed; rather than expressing emotional reactions directly, they speak of physical pain. This confusing behavior results in ineffective interpersonal communication, rendering somatizing patients less tolerant of distress and less able to deal with interpersonal conflicts. They communicate their distress and anxiety about the adequate provision of care by escalating their demands for care via somatic symptoms.
This pattern of anxious attachment and consequent interpersonal behavior is typical of somatizing patients.65 Such patients are characterized by persistent attempts to elicit care from their families and physicians, but because of the patients' insecure attachments, they find that reassurance is never adequate. Their anxious attachment is reflected in constant care-seeking behavior that is consistent across relationships and over time. Under stress, such patients often escalate their care-seeking behavior, presenting to multiple physicians with multiple physical complaints. They may also seek proximity to care providers in the form of physician office visits, emergency room visits, or frequent emergency phone calls.
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Interpersonal Communication and Somatization
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Attachment behavior is a form of communication that occurs in interpersonal relationships. As noted earlier, interpersonal responses to care-seeking behavior are crucial in the development of working models that inform attachment behavior, and also determine the intensity of such behavior. In addition, once care-seeking behavior is displayed, the interpersonal responses of attachment figures largely determine whether the behavior will be reinforced or extinguished.
A person's illness behavior may be interpreted by potential caregivers in many ways, including an appropriate response to pain, an irritating appeal for attention, or an expression of anger. The alexithymic communication style of somatizers is often ambiguous or confusing and is easily misunderstood by others.66 Rather than communicating a need for care or reassurance directly, somatizing patients frame their needs in terms of physical suffering. Potential care providers may then focus exclusively on the physical symptoms of the somatizer, ignoring the person's unexpressed psychological need for care.
Moreover, this type of care-eliciting behavior tends to provoke ambivalent responses from health professionals.65 These include a desire to care for ill patients as well as resentment toward those who are noncompliant or persistent in their complaints. Henderson65 states, "adoption of the sick role is permissible only when the disability is considered genuine and when the individual cooperates in efforts to return him to health. To assume the sick role in the absence of demonstrable or understandable disability is an infringement of the code relating to illness behavior, a code which is held especially strongly by professionals designated as health workers." Chronic care-seeking behavior in the form of persistent illness behavior is viewed negatively by physicians, and patients who display such behavior are avoided, disparaged, and dismissed.
Though the maladaptive and anxious attachment behavior of somatizing patients initially elicits a caregiving response, persons with extreme patterns of insecure attachment will continue to manifest insistent care-seeking behavior despite heroic attempts at reassurance by caregivers. Inevitably, caregivers become alienated and exit the relationship. This characteristic interpersonal cycle is ultimately interpreted by the insecurely attached person as further proof that he or she will never receive adequate care.67
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DISCUSSION AND CONCLUSIONS
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We believe that somatizing behavior is best understood as a unique form of interpersonal behavior that is driven by an anxious and maladaptive attachment style. Somatizing behavior is fostered by real or perceived rejecting responses from significant others. Somatizers attempt to elicit care by using persistent complaints of pain or physical illness. The self-defeating nature of this behavior ultimately leads to rejection by others and further fuels the patient's somatic complaints.
The primary clinical implication of this pattern of interpersonal interaction is that physicians must take responsibility for breaking these self-defeating cycles of behavior. Recognizing somatizing behavior and understanding its genesis may allow physicians to assume a more empathic stance with their patients. Physicians must be responsible for their own reactions to somatizing patients, recognizing that such patients behave in a way that typically provokes a hostile or rejecting response. Rather than being drawn into the patient's self-defeating interpersonal cycle, physicians should maintain a consistent caregiving stance. Appropriate limits must be set, but the physician must also make it clear that he or she is accessible to the patient, for it is this accessibility, rather than technical medical interventions, that is the crux of the treatment. Moreover, physicians must recognize that patients with somatoform disorders truly suffer. Their suffering may not result from severe physical pathology, but they experience a great deal of distress because of their fixed belief that they will not be cared for. Such distress is every bit as disabling as depression or anxiety and should be treated accordingly.
Further research on the effects of physician education upon somatizing behavior is clearly necessary. The success of a study by Smith et al.,68 in which primary care physicians were given recommendations for the management of somatizing patients, suggests that modification of physician behavior may have a beneficial impact on patients' use of services and their perception of health. Additional research is also needed about the use of psychosocial interventions for those patients who can be persuaded to seek psychiatric care, particularly psychotherapies that address patients' attachment behavior and interpersonal communication.
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REFERENCES
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ABSTRACT
INTRODUCTION