At the time of your interview, her posture is relaxed and she shows no signs of anxiety. These 2 very different patients whose cases I will review in detail share a common problem: somatization, the translation of emotions into somatic problems or complaints. It is well documented—though still largely unrecognized in practice—that somatization accounts for a large proportion of office visits to primary care physicians as well as specialists, 1 , 2 leading to unnecessary testing, treatment, and hospitalization, disability and corporate financial loss, 3 likely earlier mortality, 4 and frustration for patients and physicians.
Despite the burden somatization places on the medical system, the diagnosis is often made by indirect methods such as checklist, speculation, or exclusion when other problems are ruled out.
Based on recent quantitative and extensive case-based research, specific emotion-focused brief therapies and videotape-based research have clarified how emotions are experienced in the body and how somatization of emotions occurs see The physiology of emotions.
These methods, including short-term dynamic psychotherapy STDP have been used to diagnose and treat somatization effectively since the s. Somatization, with its morbidity and chronicity, need no longer be diagnosed by exclusion nor treated palliatively without specific diagnostic testing. To diagnose and manage somatization we must know how emotions are experienced and how they may become somatized.
Davanloo discovered through studying several hundred case videotapes that specific emotions manifest in specific ways regardless of gender, age, or ethnicity. Guilt about rage is experienced with upper chest constriction or even pain, intense painful feeling with waves of tears and with thoughts of remorse about experiencing the rage. When feelings are intense, frightening, or conflicted, they create anxiety and defense mechanisms to cover the anxiety see the Figure. If these feelings are unconscious to the patient, the subsequent anxiety and defenses may also be outside of awareness.
This is the finding common in people who have been traumatized by someone close to them: feelings of rage toward a loved one are unacceptable, frightening, and avoided through somatization and other defenses.
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Videotaped case-series research shows 4 main patterns of somatization: 1 striated muscle unconscious anxiety, 2 smooth muscle tension 3 cognitive-perceptual disruption, and 4 conversion. Striated muscle tension due to unconscious anxiety manifests through hand clenching, sighing, and even hyperventilation that the patient is not aware of. These patients may report panic attacks, chest pain, headache, fibromyalgia, and other musculoskeletal complaints. These conditions are often frustrating to family, employers, and physicians since conditions like chronic pain respond to treatment slowly or not at all.
I did not note any increased tension or stress during the substantive part of the interview. Based on the story and my observations, I assessed that she was being truthful and proceeded to the next stage of my investigation.
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After conducting the required background investigation, I obtained a search warrant, seized the marijuana and arrested the suspect. I verified more of the information the witness provided at each stage of the investigation, becoming even more confident in the truthfulness of her story.
As a result, I was reasonably confident I would also charge the suspect with the assault offences but it was still important for me to speak with him, get his side of the story and make my own observations of his behaviour. After ensuring the suspect had been cautioned and told of his right to counsel, I established a rapport with him. He was very relaxed and comfortable with me, speaking openly and leaning back in his chair with open body language. He remained relaxed when speaking about the marijuana cultivation because he knew he was already caught for that.
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His demeanour changed when I began asking him about the offences related to his wife and children. His responses became evasive and his bodily language closed up; he sat up, crossed his arms and legs and turned his face away from me. The only time he denied assaulting his wife he leaned to the side and picked lint off the carpet. These observations made me more confident in my conclusion and inspired me to press until I obtained admissions. As mentioned above, the first step is to establish rapport and create an atmosphere where truth is of the utmost importance.
Connecting with a subject on a personal level and gaining their trust makes them more likely to be honest and forthright. A calm relaxed person is in a much better position to access their memory because it is more available to them when they are not stressed. There is no one sign a person displays or behaviour you can observe that is a proof positive they are withholding information or lying. The formula is to establish a baseline for the their behaviour and watch for changes.
The changes in both language and non verbal signs appear as a result of stress, in most cases because the person is being deceptive or withholding information. The observations will continue throughout the interview and you will watch for clusters of changes. Do not jump in after one such change and call the person out.
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In my interview with the son in law, his evasive language was accompanied by several non verbal body language indicators. Other signs may include personal grooming, picking lint, scratching, changing arm or leg position, changes in eye contact, licking lips or hard swallowing, cracking knuckles and nervous cough or laugh.
Watch for changes from the norm. The most important principal is to be attentive when people are speaking with you and watch for some of these signs.