Looking at Significant Stressors What Else Can Account for Somatic Symptomatology

One of Jenna's most challenging clients during her first semester of training was a histrionic female freshman who presented with vague somatic complaints, including headache, muscle aches, and weakness. Examination at the campus medical center failed to find any physical cause to account for the symptoms. During the standard intake interview, the student was asked to report significant recent stressors, which included leaving home to attend the university and a breakup with her boyfriend back home. When asked about her current feelings, the student responded with global impressions that obviously exaggerated her situation. "I feel so awful, like a million tons of bricks just fell on me. I'm so depressed I can't stand it," she would say, and then pause, waiting for Jenna to provide the solution. When asked what she found most attractive about her ex-boyfriend's personality, she responded, "Oh, I don't know ... he was just so awesome." Reflecting about the inner lives of others continued to be a problem for her throughout the remainder of therapy. As she finally began to reflect on her own identity and feelings some semesters later, her somatic symptoms began to abate.

They present themselves in a socially acceptable light, maximizing impressions of health and minimizing or even omitting negative characteristics, behaviors, and symptoms that might become an important focus of treatment, if only they were known. Compulsive interviewers sometimes overestimate pathology when confronted with subjects who appear overly frivolous or grandiose, such as the histrionic and narcissistic personalities. In contrast to the compulsive, the masochistic personality is invested in bringing harsh punishment on the self; masochists may, therefore, overadmit to problems.

Sometimes, distortions of reality are corroborated by two or more individuals because of the personality dynamics of their relationship. A narcissistic member of a couple may damn his masochistic counterpart for her failings, while the masochist sits in agreement. To an interviewer focused only on verbal report, the masochist is the problem and, therefore, the proper focus of treatment. Functionally, however, the masochist is what family therapists refer to as the identified patient, the scapegoat whose symptoms help a pathological system limp along. Both subjects distort reality at a level below conscious awareness. The influence of personality style factors in limiting the validity of information, then, extends across both the patient and other informants.

Dissimulation

Some personalities consciously distort information to somehow take advantage of the system or to avoid some unpleasant consequence of their own behavior. Antisocials and histrionics, for example, sometimes fake illness if they believe there is something to gain in doing so. Perhaps the antisocial would rather spend time in a psychiatric facility than a prison, for example. Similarly, informants close to the subject, even a spouse or a family member, may have their own agenda, leading to distortions or omissions. Informants may underpathologize their report to avoid embarrassment to the family, for example. Alternatively, they may overpathologize the subject to secure some reward, perhaps continued social assistance. Most self-report instruments have indexes that can detect attempts to fake good or fake bad, though they must be interpreted cautiously in the context of other test information. Whatever the situation, clinicians are always advised to keep the principle of self-interest firmly in mind.

State versus Trait

Most patients who require psychological testing present with one or more Axis I disorders. Traits refer to long-standing personality characteristics that endure over time and situations. In contrast, states refer to potentially short-lived conditions, usually emotional in nature. Anxiety, depression, and loss of reality contact can all affect the results of personality testing. J. Reich, Noyes, Coryell, and Gorman (1986), for example, obtained personality profiles on a group of persons with panic disorder and agoraphobia. Those judged improved six weeks later showed significantly increased emotional strength and extroversion and significantly decreased interpersonal dependence. Some disorders also have a motivational or cognitive dimension that can affect the validity of test results. Depressed individuals report increased feelings of worthlessness and shame, which can lead to overendorsement of items intended to assess low self-esteem as a personality trait, for example. Research on mood-congruent memory shows that different emotional sets make different schemata more available, negatively biasing reflections on self, world, and future (Beck et al., 1990). Problems with concentration and low energy can make depressed persons more indecisive, which superficially resembles a characteristic of the dependent personality, who needs help making decisions. Some questions tap both state and trait characteristics because of their wording. An item such as, "I am a very dependent person," will be answered affirmatively by both dependent personalities and those whose Axis I disorder or physical condition forces them to rely on others, however resistant they might be. Subjects desperate for help sometimes use the assessment as a means of communicating their helplessness. By adopting a low threshold for answering any item in a pathological direction, they inflate scores almost everywhere in the inventory. Crossover effects from state to trait are an expectable part of assessment and must be considered by whoever interprets the test results.

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