somatization

• Therapeutic Interventions with Shame by Ed Schmookler, PhD., 5/6/96
  • What to do with shame by Jim Pfrommer, 5/7/96
    • Somatization and Avoidance by B.B., 12/31/96
      
      

Let's start with the obvious: All affect is initially somatic. It is our interpretation of the gestalt formed by the events at the various sites of action associated with any particular affect that allows us to assign an experiential name to that gestalt. If the nine innate affects can be likened to a bank of spotlights, each of a different color, each turing on and off as its specific trigger is accessed by some pattern of stimulation, then it is easy to see that paying attention to an affect means nothing more than focusing on whatever has triggered the affect and is now illuminated or made more visible by that affect. People who cannot (for a number of reasons) process this site-of-action data as affect are trapped in a recursive pattern---since each affect is an analogue of its stimulus characteristics, then each affect is also a competent trigger for more of that same affect. This is sometimes called "internal contagion" and is the reason that affect that is ignored rises in intensity until the one who needs to ignore it is faced with powerful, intense activity at one or another site of action. It is for this reason that people who ignore mild degrees of fear-terror may therefore allow the affect to rise in intensity until the slightly quickened heartrate of fear is amplified to the terrifying pounding and racing heart of a panic attack.

The same may be said of any affect. In the case you present, chronic fatigue (if not a post-viral syndrome) may be thought of as the affect distress-anguish triggered by some steady-state noxious stimulus. Disavowal will do that, disavowal of some mental or physical stimulus that just goes on and on and cannot be approached because of the sort of personality quirks we are called on to fix.

In general, then, when good physicians are unable to find an illness that has caused the discomfort at one of the normal sites of action for an affect, I try to assess the quality of the discomfort to see which affect profile it fits. Steady, boring pain is somewhere on a continuum between distress-anguish and anger-rage (think of all those patients we've seen with headaches that disappear when the patient finally gets angry at the provocateur!!); disjunct sharp spasms of pain may be related to fear-terror or sometimes surprise-startle; and so forth.

As for the specific patient you describe, I have often found it useful to ask the patient to speculate about what s/he might do were this pain syndrome (or whatever) disappear or be cured by some magic wand. And sometimes I ask the patient something like "If this pain were some kind of weather, what would it be like?" Any way I can get an image from the patient I am 'way ahead of the game.

I think we get trapped too often in the history because it is easy to say that the drama of her life must be related to the illness of the moment. Doubtless she has developed this (possible) disavowal of her affects because of things that went on in her childhood, but I don't think that will be important until you have given the pain a label. Remember that scene in the Batman movie when Jack Nicholson's Joker sees the Batman on a television screen and says with all the venom he can muster "At last I have a name for my pain!"

Finally, your question about shame. The clinical situation you describe may well be one form of a chronic shame syndrome experienced not as avoidance (a term I coined to represent a library of scripts involving ways to decrease shame by focusing attention away from whatever has been revealed, by drugging it away--alcohol works great here--so that they feel nothing, or by substituting some dangerous or exciting scene to override the shame experience) but more as the withdrawal pole of the compass of shame. You might test your hypothesis by giving her Cook's ISS (Internalized Shame Scale).

I'd appreciate any followup you might be able to provide.

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