A mentalization-based approach to the understanding and treatment of functional somatic disorders

Abstract

Patients with functional somatic disorders (FSD) represent a sizeable group in our health care system. FSD are associated with high health care use and considerable personal and economic costs. Evidence-based treatments for FSD are only modestly effective in a large subgroup of patients, particularly in the long run, which emphasizes the need to develop more effective treatments rooted in extant knowledge about the nature of FSD. This paper presents a contemporary psychodynamic perspective on the conceptualization and treatment of patients with FSD rooted in attachment and mentalization theory. First, we review animal and human research demonstrating the close relationships among attachment, stress regulation, and immune and pain-regulating systems. We highlight research findings concerning the high interpersonal and metabolic costs associated with the use of insecure secondary attachment strategies (i.e. attachment deactivating and hyperactivating strategies) leading to increased vulnerability for stress. Next, we review evidence for the role of impairments in (embodied) mentalization in patients with FSD both as cause and consequence of functional somatic complaints, leading to the re-emergence of so-called non-mentalizing modes, i.e. modes of subjectivity that antedate the capacity for full mentalizing. Based on these views, a novel brief psychodynamic intervention for patients with functional somatic complaints is presented.

Keywords:

• functional somatic disorders
• somatoform disorders
• mentalization
• attachment
• stress

Notes

1. This is also the reason why we prefer the label of ‘functional somatic syndromes’ or ‘persistent somatic complaints’ over other diagnostic labels such as ‘psychosomatic’, ‘somatoform’ or ‘medically unexplained’ syndromes. As we shall see, although the causation of these syndromes remains poorly understood, they are far from ‘medically unexplained’, as a variety of biological factors have been implicated in their etiology and pathophysiology. Similarly, notions such as ‘psychosomatic’, ‘somatization’ and ‘somatoform’ disorders unduly emphasize the primacy of psychological factors or attributions in the causation of these disorders.