Somatization and the sociology of health

June 15, 2014

I’ve written about pain-silencing dynamics in this blog before, but not pain-simulating phenomena, partly because I was uncomfortable with exploring the distinction.

Naming sense perceptions doesn’t feel like a reflective process, the labels are intuitive, pre-conscious, self-evident. Somatization is a radical critique of that accomplishment in self-assessment, a formal medical negation of the patient’s authority on what is of the body, and what is of the imagination, instead. In the treatment of chronic pain, somatization is the verdict that the patient’s mind is inducing or confabulating discomfort where there is no organic cause.

Somatization is strongly associated with a history of violent victimization, anxiety disorders, depression and ongoing relationship problems. Vicious cycles and chronic vulnerabilities are characteristic of the natural history of this psychological disturbance. The body registers complaints that are posited to be more psychosocial in nature, wincing so hard it hurts, so to speak.

The social determinants of health are best represented in a flow chart of interdependent factors promoting wellness or vulnerability, respectively. Their interdependence makes slipping into a “poverty trap” of mutually reinforcing vulnerabilities a very likely and treacherous outcome, especially for victims of family violence denied a healthy foundation of psychosocial and socioeconomic support. The situational drivers of somatization are typically chronic in nature, representing very real and concrete barriers to health and well-being.

social-determinants-of-health-flow-chart

Like stigmata, somatization announces itself ingloriously as a demonstrative and intractable discontent. Sternbach’s 6 D ‘s of Chronic Pain Syndrome are:

• Dramatization of complaints
• Drug misuse
• Dysfunction/disuse
• Dependency
• Depression
• Disability

The first bullet in this list grabbed my attention when I was reading about chronic pain. A pain patient who has resorted to dramatization in encounters with doctors is someone, I think, who is rebelling against silencing pressures and trying to “dumb down” the explanation of onslaughts from an invisible enemy within to a willfully obtuse audience. Pain is nothing if not acutely real to the patient, and being told that it’s a psychological phenomenon is profoundly frustrating.

But chronic pain ebbs and flows, and can be exacerbated by psychosocial triggers and cues. Body memories, bone bruises and imperfectly healed fractures blur together in a continuum of sub-clinical, psychologically amplified complaints that confound general practitioners leery of drug-seeking behaviors in agitated patients whose problems are clearly complex and chronic. The absence of a billing mechanism for assault injuries (there’s no insurance for that) further muddies the waters and breeds mistrust between doctors and patients.

social-determinants-of-health

Word games and silencing strategies are difficult to disentangle from mindless routines and cynical billing mechanisms in clinical practice. Institutional violence and interpersonal violence are related, in the form of services gaps, prohibitive transaction costs for prosecuting assault cases and stigmatizing victim stereotypes. When an assault victim is diagnosed with somatization, a dead end of sorts has been reached in the Kafkaesque labyrinth of impersonal mechanisms for redressing ill-health and ongoing vulnerability to revictimization.

In a discussion of political torture, Elaine Scarry describes the dyadic dynamics of oppressive violence as ritualistic in use of interrogation modes – “the question” is socially constructed as “the motive” and “the answer” is ritually interpreted as “the betrayal” and provocation for further violence. She notes that political torture employs interrogation routines even when the motive is punitive and information-gathering is not at issue. She defines torture as a demonstrative use of power and fiction aimed at achieving psychological abnegation in the victim.

Chronic interpersonal violence simulates this dynamic in a mundane microcosm of entrapment strategies and multidimensional abuse. Verbal self-assertion is punished with physical assault, and victim-blaming tropes are mobilized to suppress any effort to redress injury or standing threats.

Somatization of repressed complaints is a common outcome, carrying the radical embodiment of memories of wounding to tautological extremes. What is not to be spoken of is nevertheless etched in awareness like writing on the back of an eyelid, garish and surreal.

Rape myth research gives a typology of generalizable victim-blaming misconceptions:

• Victim masochism (they enjoy it or want it)
• Victim precipitation (it only happens to certain types of women)
• Victim fabrication (they lie or exaggerate)

The officially fabricated nature of somatic complaints adds insult to injury in confrontation with clinical practice. The search for answers is turned back on the victim’s propensity for attention-seeking behaviors rather than their vulnerability to wounding.

If the psychosocial triggers of somatization include cohabiting relationship violence, housing insecurity is outside the doctor’s purview and the result can be a treatment plan that second-guesses the patient’s most pressing anxieties (by bringing the patient’s sanity into question) and only promotes further repression and dissociation. I’ve had this experience as a patient who was in treatment for complaints driven by family violence while I was still living with my abuser.

Isolation, monopolization of attention, induced emotional exhaustion, threats, occasional indulgences to motivate compliance, demonstrative omnipotence, degradation and the enforcing of trivial demands to develop a habit of compliance have been identified as systematic mechanisms of oppression in penal institutions that violate human rights (from Biderman’s chart on penal coercion in a 1973 Amnesty International Report on Torture). These are generic stratagems for psychological abnegation that can be reproduced in any cohabiting relationship in which dependency for instrumental support simulates conditions of captivity. They promote dissociation and somatic illusions that are pervasive and easily triggered by proximate fears.

The salience of somatization is more clear to me now that I have my own place and can put significant social distance between myself and my family. Ironically, what used to register as an oppressive label and a silencing strategy on the part of empty handed service providers now has a liberating effect on my sense of self-efficacy in coping with chronic pain.

For me, overcoming somatization involves awareness of confirmation bias in my own thinking, and of the way muscles tense uncomfortably when further pain is anticipated as a logical sequelae of the assertion “this pain I am experiencing is real.” As long as I can register a passing discomfort as genuine without seizing on anticipation that it will persist, I can cope with sensations that used to be more persistent and more sensitive to triggers of the uncanny.

Discomforts that used to be frightening to me now register as familiar but transient, reminders of long-healed bruises rather than urgent alarms about seemingly unremediated harms. I’m finally comfortable with interpreting the pain as a metaphor, a physical expression of feelings that have significance even if they aren’t “organic” in nature.

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