Have you ever become worked up about some medical symptoms that turned out to be “all in your head”? Most people can recall worrying about the occasional odd sensation, bump or rash, only to be reassured by their doctor that everything is fine. Most of the time, that reassurance is all that’s needed to set things straight. But occasionally these vague symptoms may start to drive more frequent visits to the doctor, prescriptions for medications that are unhelpful, a long chain of specialist appointments, and the troubling insinuation that perhaps stress is at the root of the problem and counselling is required.                                                       

Are We Just Looking for Attention?

Somatization is a medical term for these kinds of problems. The word Soma refers to anything to do with your body, though the term somatization is much more specific to medical symptoms that defy a diagnosis and elude effective treatment. Often the implication is that these kinds of problems are “functional”, meaning that they serve a purpose in expressing psychological needs as opposed to actual physical disease or injury. To give a simple example, when I was a young child I had frequent stomach aches that always coincided with the start of school. I did not intend for this to happen, but my nerves got the better of me and helped draw attention to my plight. Physical symptoms can work this way for adults too, in that they express underlying worries or the effect of stress that needs to be addressed more effectively. Symptoms like these have been a big part of my work as a clinical psychologist, particularly as I made the career choice to work closely alongside physicians, who are often frustrated by “functional illness” and are keen to refer them for psychological treatment. 

The idea that a medical problem is “all in your head” is hardly flattering, and certainly offers no reassurance to anyone suffering from these sorts of symptoms. The phrase is meant to imply that you are imagining things that don’t exist. Yet recent research is beginning to focus on an interesting and somewhat paradoxical fact - It seems that regardless of the type of medical complaints that underlie somatization problems, there are some pretty consistent and measurable changes in the way the brain works that can actually be seen using high tech imaging methods like fMRI scans. 

New Research Sheds Light on the Problem

I’ve been trying to make sense of the neurologically based research on somatoform disorders for years, but most of the studies used very small samples of people and their results were rarely confirmed by independent research. So when I spotted a recent article confirming that there might be some consistency to changes in the brain that help explain these problems I was very, very interested. The paper was published by Boekle et al. (2016) and looked at hundreds of studies that have been carried out on somatoform disorders. They were looking at research into the problem that used neuroimaging techniques such as functional magnetic resonance imaging (fMRI), Positron Emission Tomography (PET) and Voxel Based Morphometry (VBM) to create actual pictures of the brain in action in order to compare different groups of patients. 

When brain imaging is used in this sort of research, the goal is to find differences between activity in various locations, or “foci” when comparing people with a particular diagnosis and a “control group” of people who are healthy and do not have the diagnosis. The assumption is that if you have a particular psychological disorder, this should be evident in the way that your brain processes information within and between its various circuits (functional differences) or in the size and shape of these areas or circuits (structural differences). In the case of the studies being scrutinized by Boekle et al., close to 100 such foci were included in their search. In the end, five areas showed differences between the two groups. I’ll walk you through each of these “foci'' one at a time and include a description of the location and function of each part so that you can start to get an idea not just about what drives somatization disorder, but how we all process thoughts and feelings about our health worries:

The Circuit Breaker: Anterior Prefrontal Cortex 

This part of your brain interacts with the Anterior Cingulate Cortex (“the Change Detector, see below) when you are expecting or predicting bad outcomes. It’s an activity that cognitive therapists call “catastrophizing” when it is exaggerated and happens too frequently. The brains of people with chronic back pain show this same pattern of activity and connections. Furthermore, there are structural changes in the brain here such that the Anterior Prefrontal Cortex is smaller than normal. 

The Engine Room: Premotor and Supplementary Motor Cortex

When a person is experiencing chronic pain, or is fearful of injury and the associated discomfort it will bring, they will change their behaviour dramatically. Often they'll become overcautious and avoid exertion and physical activity in general. The reduction in activity causes the parts of the brain required for movement to shrink – hence the premotor and supplementary motor cortex has been observed to be less active and smaller in size for people with chronic pain and specific pain conditions like fibromyalgia and irritable bowel syndrome. This kind of change is structural and reflects the old saying “if you don’t use it, you’ll lose it”.

The Reflector: Dorsal Posterior Cingulate Cortex

This part of your brain shows both changes in its size and in the way it functions in the case of somatoform disorder. It is a key part of a brain circuit called the Default Mode Network, which is involved in day dreaming and self referential thinking (thinking about yourself and your life). The Dorsal Posterior Cingulate Cortex is overactive in somatoform disorder and this probably reflects a tendency for people with the problem to ruminate too much about their symptoms, their health, and negative implications for life in general. Not surprisingly, it’s also very active and involved in other psychological problems, like depression and schizophrenia, two illnesses that usually involve a great deal of self-referential thinking. 

The Change Detector: Anterior Cingulate Cortex

This part of the brain is essential to human thought and how we make sense of emotions. It is very intimately involved in detecting discrepancies or conflict either in your own internal thoughts and sensations and also in what you perceive others are doing and thinking about you. It has been associated with the detection of social exclusion (being ostracized) and violations of expectancy. This can influence our self-esteem, sense of meaning to our existence, control over things, and sense of belonging. The Anterior Cingulate Cortex is involved in the detection of physical pain and serves as a sort of alarm system alerting us to changes that indicate harm or injury.

The “Expector”: Insula 

The Insula is very involved when you are thinking about and experiencing pain. Some studies have demonstrated that when you are expecting pain, but it is not yet happening, the insula is very active. In somatoform disorders it is over active and felt to be responsible for a magnified expectancy and attention to painful experience. Not surprisingly, this same area is involved in the expectation and experience of emotional pain, and is very active in problems like depression. People with fibromyalgia, a disease where your whole body seems to ache and throb, show a lot of activity here and they can be hypersensitive to small sensations that healthy people do not even notice. 

Putting it all together: the “Pain Matrix”

When taken together, this collection of brain parts has been of interest to clinicians for a long time. It has been given a variety of names, including the “neuromatrix” and “pain matrix”. It involves parts of the brain that are involved in pain sensitization, a phenomenon where the brain becomes hyper alert to even mild physical stimulation and reacts with exaggerated symptoms of physical and emotional discomfort. This same type of sensitivity is involved in many other kinds of problems, including anxiety disorders and depression, where a person’s emotional reaction may become sensitized and out of proportion to events around them. It is perhaps for this reason that many different types of emotional problems can be treated using similar methods, whether these involve medications or psychological treatment techniques like cognitive behavioural therapy. 

This existence of a “pain matrix” also explains why simply reassuring someone that “it is all in your head” will not help much. We are dealing with something that involves real changes in the brain and the way it processes information. These sorts of changes often reflect vulnerabilities that a person has inherited (genetics), or learned over time (parenting, traumatic experiences, habit learning) and cannot be undone simply by recognizing that they exist. Furthermore, the presence of both “functional” and “structural” changes in the brain in the case of somatoform disorder suggests that the worry, pain and discomfort that sufferers experience is as real as the suffering that goes with most “organic” medical problems. Real and unique features in the structures making up the brain and the functional connections between these brain parts appear to be associated with the symptoms of somatoform disorder, and it will take real changes in thinking and behaviour practiced over time to correct the “dysfunctional connections” that are contributing to its symptoms. 

While there is still a lot of speculation and conjecture involved in this kind of research, these findings help confirm that no matter what you think, feel or do, your behaviour is influenced by and influences the way the circuits of your brain function. Psychological problems often do not reflect a medical disease or illness so much as they indicate a solution that the brain has come up with for processing information that magnifies natural functions to the point where they become inefficient and counterproductive. For this reason, efforts to look more closely at what is actually going on in your head is the key to helping all of us challenge our assumptions about why we feel better or worse than others.

References:

Boekle, M., Schrimpf, M., Liegi, G, & Pieh, C. (2016). Neural correlates of somatoform disorders from a meta-analytic perspective on neuroimaging studies. Neuroimage: Clinical. 11, 606-13