attention,verbal learning and memory deficits in somatization disorder

8/10/2019 Attention,Verbal learning and Memory deficits in Somatization Disorder

1/21

International Journal of Applied Research and Studies (iJARS)

ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014)

www.ijars.in

Manuscript Id: iJARS/895 1

Case Study

Attention, Verbal Learning and Memory deficits in Somatization

Disorder: A Pilot study

Authors:1Ansha Patel*, 2Korsi Dorene Kharshiing

Address For correspondence:1 Clinical Psychologist and PhD Scholar, Department of Psychiatry, Kasturba Medical College, Manipal

University, Manipal, Karnataka.2Assistant Professor in Department of Psychology, Jamia Millia Islamia, Jamia Nagar, New Delhi.

Abstract & Summary:

Recent Neuropsychological conceptualization and research evidences suggest deficiencies in information

processing, receptive and expressive functions in Somatization Disorder and its plausible association with

significant socio-occupational impairment. However, there exists a dearth of literature in exploration of

cognitive complains reported by patients with Somatization Disorders. The objective: The present research

aimed to carry out a preliminary investigation that assesses, and examines the basic lower cognitive abilities

like attention, verbal learning and memory deficits in patients diagnosed with Somatization Disorder versus

a group of normal subjects. Method: The study was carried out on 15 male patients diagnosed with

Somatization Disorder as per ICD-10 CDDG, aged 20-30 years, in comparison to 15, gender, age, socio

economic status, education and background matched normal subjects. The subjects were assessed on testsfrom The Nimhans Battery (Rao, Subbakrishna, Gopukumar, 2004), The Color Trails Test (D'Elia, Satz,

Uchiyama, White, 1996), The Digit Vigilance Test (Lezak, 1995), The Triads Test (Nimhans version,2004),

The Auditory Verbal Learning Test (Maj et al.,1994)and The Passages Test (Mukundan, Reddy, Hegde,

Jayanthi, Kaliaperumai, 1987).Results:Significant cognitive deficits were found in the Somatization patient

group in comparison to control on subdomains of Sustained Attention, Divided Attention, and on all

subdomains of auditory verbal list learning and memory. No significant deficits were found on the

subdomains of focused Attention and Logical Memory. Conclusion: Evidences of this pilot study suggests

that Somatization Disorder is associated with Attention, Verbal Learning and Memory deficits that needs to

be investigated elaborately in consideration of function impairments faced by such patients in their day to

day lives.

.

Keywords:Somatization Disorder, cognitive deficits, attention, verbal learning, memory

[email protected]*Corresponding author E-mail Id
mailto:[email protected]:[email protected]:[email protected]


2/21



www.ijars.in


I. INTRODUCTION AND REVIEW OF LITERATURE

The term Hysteria has been studied as a somatic syndrome, for the peculiar ways in which the body

converts psychological distress to physical symptoms, with a myriad of cultural manifestations.

Contemporary mental health professionals have given up the use of the medical disease concept of

"hysteria"; and replaced it with somatic symptom and related disorders (DSM-V) and somatoform and

dissociative disorders (ICD-10), cataloguing it in the wider framework of psychosomatic", "functional",

"nonorganic", "psychogenic", abnormal illness behaviour and "medically unexplained" illnesses. Review

studies on the epidemiology of this disorder, have suggested that among the different types of Somatoform

Disorders, the subtype Somatization Disordercarried the highest diagnostic reliability, validity and is the

commonly reported variety of the later disorder (Garcia-Campany, Lobo , Perez-Echeverria and Campos,

1997,1988,2001 and Fink 1996, 2005). Theoretically, Somatization Disorder is often defined as the

propensity of the patient to experience a multiplicity of unexplainable physical /somatic symptoms, with

several organs affected, that have no pathophysiological explanation, considered by clinician as "medicallyunsolved problem" (Lipowski, 1988).With a reported prevalence rate of 3.3% in India , rural urban ratio of

100:44 (Ganguli,2000),common age group of 10-25 years, significant morbidity has been reported in Indian

unmarried males, who are diagnosed with Somatization Disorder (Vyas, Bharadwaj, 1977, and Bagadia,

Shastri, Shah ,1973). Since the last decade, owing to cognitive revolution in psychology, a plethora of

research evidences have emerged in the field of psychopathology, that have highlighted the role of

neurocognitive deficits as causative factors in emotional disorders. Research evidences have also used the

same information processing paradigms to describe the cognitive processes associated with evidences of

brain dysfunction in patients with Somatoform Disorders (Almgren, 1978). Additionally research works

carried out by Serra, Fadda, Buccione, Caltagirone, Carlesimo (2007) and Hakala (2008) have proposed

neuroradiological, neuropsychological, psychopathological evidences in Somatization Disorder.

Furthermore, brain imaging studies have demonstrated bifrontal cerebral impairment, particularly in the non-

dominant hemisphere (Flor-Henry, Fromm-Auch, Tapper and Schopflocher, 1981); particularly in

prefrontal, temporoparietal and cerebellar areas in Somatization Disorder(Garcia-Campayo,Sanz-Carrillo

and Baringo , 2001). Literature reviews on neurocognitive deficits in Somatization Disorder illustrates that it

is characterized by specific cognitive features (Rief and Nanke, 1998). Additionally, research evidences

highlighted by studies of Shapiro (1965), Ludwig (1972, Lane and Schwartz (1987), Niemi, Portini, Aalto,

Hakala and Karlsson (2002), Merkel (2003) and Trivedi, Sharma, Singh, Tandon (2005) suggests that this

disorders are particularly associated with scuttle cognitive impairments like features of attentional

distractibility, inability to habituate attention, partial or circumscribed associations, lack of selectivity andcontrol of attention and memory, deficits in information-processing, emotional processing and spatial

working memory. Furthermore, the later authors also noted that, cognitive complaints are protuberant in

50%-85% of patients with Somatoform Disorders/ Chronic Fatigue Syndrome, which contribute

considerably to their social and occupational dysfunctions. The effects of information processing deficits in

Somatoform Disorders have been documented by several researches. Studies by Ott, Spielberg and Scholz

(2000) on such patients have demonstrated that they have a biased priming towards threatening stimuli;


3/21


4/21



www.ijars.in


8. There will be significant differences in Delayed Recall of Logical Memory Test in patients with

Somatization Disorder and normal subjects.

III.

THE METHOD AND MATERIALS:

Method: Design and Sample Size:The study was conducted implementing a two group design, group 1 was

patient group and group 2 was normal control group. Sample size was time bound to a period of 6 months,

and comprised of 15 patients per group, with a total sample size of 30 patients. The sampling method:

Purposive sampling was used to recruit consenting subjects after seeking ethical permissions from various

private hospital setups in Delhi. Sample recruitment:The patient group (Group-I) comprised of 15 married

male subjects, employed, college educated individuals from middle socio economic status, who were known

cases of Somatization Disorder(F 45.0) as per ICD-10 (CDDG), diagnosed in the last 2 years, not on any

medication since the past 4 months; on the other hand Group-II comprised of 15 subjects who were gender,

age, education, SES and background matched normal subjects, who were usually patients knownacquaintances, not diagnosed with any general medical condition, and not on any other medication. A socio-

demographic and clinical data sheet was used to record details like age, sex, , marital status, education,

religion, occupation, family background, past personal and present history of psychiatric illness, genogram,

family history of psychiatric illness, history of general medical conditions in patients and their families,

childhood history of development, marital history, pre-morbid personality and mental status examination. In

the patient group , the age of onset of illness, course and duration of the patients illnesses and treatment

were also recorded. The subjects meeting the following inclusion and exclusion criteria for the respective

study groups were considered for the study:-

Inclusion/Exclusion Criteria for Patient Group:Hindi/English speaking, married male subjects educated uptill college, between the age ranges of 20-30 years, belonging to middle socio economic status, residing in

Delhi, presently employed, meeting the ICD-10-CDDG (WHO, 1992) criteria for Somatization Disorder ( F

45.0) diagnosed in the past 2 year, not having any past or present history of substance abuse, other co-

morbid psychiatric disorder/neurological/general medication conditions(as screened and diagnosed by a

certified Psychiatrist and Physician as per ICD-10-CDDG(WHO, 1992) , not on any medications since the

past 4 month and consenting to participate in the study were included in the patient group.

Inclusion/Exclusion Criteria for Normal Subjects Group: Hindi/English speaking, married male subjects

educated up till college, between the age ranges of 20-30 years, belonging to middle socio economic status,

residing in Delhi, presently employed, screened on General Health Questionnaire-12(Goldberg & Williams,1988) as having a score of 3 or less than 3, and not having any other past or present history of substance

abuse or co-morbid psychiatric disorder / neurological /general medication conditions(as screened and

diagnosed by a certified Psychiatrist and Physician as per ICD-10-CDDG (WHO, 1992) , not on any

medications and consenting to participate in the study were included in the patient group. These individuals

were accompanying friends/acquaintances of the subjects in the patient group.


5/21



www.ijars.in


Materials :Tools used:The various domains of attention, verbal learning and memory were assessed using

the tests complied in The Nimhans Neuro-Psychological Battery. The Battery was developed by Rao,

Subbakrishna, and Gopukumar (2004).The battery consists of 19 tests, comprised in the form of tasks for

which standardized administration and normative data is available for adult Indian subjects between the agesof 16-65 years. The battery has a good factorial validity and the factor analysis on the literate sample of 120

subjects with 22 variables have been established yielding 6 factors separately, with eight values more than

one accounting for 66% of the variance. The normative data have been classified according to age (young,

middle adults old age), gender, and education (illiterates, school educated, college educated). The normative

data presented in the battery is in the form of mean and standard deviation according to age, gender and

education as well as percentiles (to indicate functioning) and cut-off scores (suggesting organic brain

dysfunction).A number of researchers conducted by Kolur, Reddy, John, Kandavel and Jain (2006), Kar,

Rao, Chandramouli and Thennarasu (2004),have corroborated the reliability and validity of the Nimhans

Neuro-Psychological Battery Rao, Subbakrishna, and Gopukumar (2004), for assessment of cognitive

deficits in various psychiatric disorders. In the present study, we have procured and used the tests complied

in The Nimhans Neuro-Psychological Battery (2004), for the domains ofAttention-focused, Sustained and

divided, Verbal Learning and memory and Logical Memory.

Attention, Verbal Learning and M emory Assessments

Measures of Attention:Attention refers to the concentration and focusing of mental effort (Matlin, 1983)-- a

focus that is selective, shiftable and divisible. The description of the types and tests of attention taken and

assessed using the Nimhans Neuro-Psychological Battery (Rao, Subbakrishna, and Gopukumar, 2004) in the

present study, is given below.

Assessment of Focused Attention: It refers to the capacity to perform a task in the presence of distracting

stimuli. The orbit frontal area in the prefrontal cortex mediates this capacity to inhibit responses to stimuli

irrelevant to the task. It was assessed using the Color Trails Test ,part 1 and part 2 ( D'Elia,

Satz,Uchiyama,White, 1996).A number of researchers conducted by Dugbarteya, Townes Mahurind(2000)

and Elkin-Frankstona, Lebowitza,Kapusta,Hollisa, OConnor (2007) have corroborated the reliability and

validity of this test for assessment of attentional deficits.

Assessment of Sustained Attention:It refers to the capacity to attend to a task in hand for a required period of

time. Right fronto parital network mediates this function.Sustained attention was assessed using the Digit

Vigilance Test(Lezak, 1995).A number of researchers conducted byKolur, Reddy, John, Kandavel and Jain

(2006), Kar, Rao, Chandramouli and Thennarasu (2004),have corroborated the reliability and validity of

the Digit Vigilance Test for assessment of deficits in attention.

Assessment of Divided Attention: It refers to the ability to attend to two or more tasks simultaneously.

Bilateral dorsofrontal prefrontal cortices mediate this function. The divided attention was assessed using The

Triads Test, which was developed at NIMHANS. It combines Verbal Triads Task with Tactual Number


6/21



www.ijars.in


Identification Task. A number of researchers have corroborated the reliability and validity of the Triads Test

for assessing deficits in attention (Dasgupta, 2003).

Measures of Verbal Learning and Memory: The Auditory Verbal Learning and Memory was assessed usingtwo separate measures, namely, learning and memory for list of words and for Logical Memory. With

respect to the same, the sub-domains of Auditory Verbal Learning and Memory that were assessed were

Immediate Recall of List of words, Delayed Recall of List of words, Total Learning of List of words, Long

Term Percentage Retention of List of words, Delayed Recall of List of words, Recognition for List of words

, Immediate Recall for Logical Memory, Delayed Recall for Logical Memory.

The Assessment of Learning and Memory for List of Words: Rey Auditory Verbal Learning Tests (RAVLT)

by Schmidt (1996)was used for assessing list learning and memory. The standard administration format of

the RAVLT-WHO version (Maj et al., 1994) was used.A number of researchers conducted by Callahan

and Johnstone (1994), Malloy-Diniz (2007), have corroborated the reliability and validity of the ReyAuditory Verbal Learning Tests for assessment of verbal learning and memory deficits.

Logical Memory Assessment: Logical memory is assessed by the immediate and delayed recall of a

meaningful passage. The passage test was used for assessing logical memory. This passage has been used in

the NIMHANS Neuropsychological Battery compiled by Mukundan, Reddy, Hegde, Jayanthi, Kaliaperumai

(1987), as well as in the PGI Memory Scale (Pershad and Wig, 1976). Research conducted by Andrade

(2001) has corroborated the reliability and validity of the Logical Memory Test for assessment of deficits in

logical memory.

The Procedure:The data for the present research was collected after taking permission from the authoritiesconcerned and after taking an informed consent from the research participants from various outpatient

psychiatric departments of private hospitals in Delhi. The patient group comprised of known diagnosed cases

of Somatization disorder diagnosed by trained certified Psychiatrists as per ICD-10-CDDG(WHO, 1992).

The normal subjects group were the acquaintances of the patient who were screened as per GHQ-12. Before

administrating the tests, a rapport was established with the research participants and a brief overview of the

nature and purpose of the research was outlined to them. The subjects consenting to participate in the study

were thereby administered the socio-demographic data sheet and the various selected tests of the Nimhans

Neuro psychological Battery (2004). The instructions of each of the test were clearly given and the

respondents were encouraged to clarify their doubts, before assessments. Moreover, the respondents were

assured of the confidentiality of their results. The data thus collected was scored as mentioned in the

Nimhans Neuro-psychological Battery manual (2004), after which the percentile scores were calculated for

each measure using the test norms as specified in the latter battery. The data on The Color Trials Test (Part 1

and 2) was scored on the basis of the total time taken (using a stop watch) to complete the tasks. The data on

The Digit Vigilance Test, The Triads Test, The Rey Auditory Verbal Learning Tests, The Passages test was

scored on the basis of total number of words/facts recalled/ errors. The total time taken per person on the


7/21


8/21



www.ijars.in


Table 1: The values of mean, standard deviation, t-value, significance level, percentile and impairment level

on dimensions of attention in patients with somatization disorder and normal subjects.

S No.Dimensions of

Attention

Study

GroupsMean Standard

Deviation

t-

value

Significance

Level Percentile

Deficit/

non-deficit

1.

Focused

Attention

(total time

taken in

seconds)

Part 1

Normals 33.8 4.3

0.16 NS

97t-100

t No

Patients 45.6 6.2 78t-84

t No

Part2

Normals 52.5 6.1

2.3 *

89t No

Patients 87.4 56.4 65t-68

t No

2.

Sustained

Attention(Total errors)

Normals 2.53 1.4

17.14 **

68t-84

t No

Patients 14.7 2.3 10t -16th Yes

3.

Divided

Attention

(Total errors)

Normals 1.2 1.4

10.6 **

66 -72th No

Patient 11.4 3.3 Below 3rd Yes

*Significant at 0.05

**Significant at 0.01

NS is not significant

Results of Focused Attention Task:The dimension of focused attention refers to the capacity to perform a

task in the presence of distracting stimuli. Table 1. Given above summarizes the values of Mean and


9/21



www.ijars.in


Standard deviation on this measure. On the basis of Table 1, results showed that the study groups did not

differ significantly on focused attention task: Part 1 (t-value was found to be 0.16). Both groups performed

adequately on this task, with no significant differences in the means of the two groups (the mean of normal

subjects for part 1 was found to be 33.8 and that of patient group were 45.6). The results were not suggestiveof any deficits in any of the study group, as the patients of Somatization Disorder obtained a percentile score

of 65th

-68th

on the focused attention task part 1, in comparison to normal subjects group who obtained a

percentile score of 89. As illustrated in Table 1 shown above, the results of the present study suggests that

the study groups differed on the total time taken to complete focused attention task: Part 2 of the test (the t-

value was found to be 2.3).Additionally, the data obtained on this measure shows that the patients of

Somatization Disorder differed with the normal subjects on the basis of the obtained means (the mean of

normal subjects group for part 2 was 52.5 and that of patient group was 87.4). The result were not suggestive

of any deficits in any of the study groups, as the patients of Somatization Disorder obtained a percentile

score of 78th

-84th

on the focused attention task part-2, in comparison to normal subjects group who obtained

a percentile score of 97th-100th.

Results of Sustained Attention:The dimension of sustained attention refers to the capacity to attend to a task

in hand for a required period of time. Table 1 given above summarizes the results of the study groups on this

measure. On the basis of Table 1 shown above, it can be suggested that, the groups differed on the total error

score obtained on the measure of sustained attention (the t-value was found to be 17.1). The data obtained on

this measure also urges that the patients of Somatization Disorder differed with the normal subjects, on the

obtained means (mean of normal subjects group was 2.53 and that of patient group was 14.7) Additionally,

the results are indicative of sustained attention deficits in the Somatization group, as it was observed that the

patients of Somatization Disorder performed poorly on the task, making more errors, with a percentile score

of 10th- 16th in comparison to the normal subjects who had a percentile score of 68-84.

Results on Divided Attention Task: Divided attention refers to the ability to attend to two or more tasks

simultaneously. As per Table 1, given above, it can be seen that the results of the present study suggests that

the groups differed on the total errors on the divided attention task (the t value was found to be 10.6);

moreover patients of Somatization Disorder performed poorly on the task with deficits in performance and a

percentile score of below 3rd

in comparison to the normal subjects who had a percentile score of 66th

-72th.

The results also suggests that the patients of Somatization Disorder differed with the control group on the

basis of the means obtained (mean of normal subjects group was 1.2 and that of patient group was 11.4).

Verbal Learning and Memory Measures

Results on Auditory Verbal - List Learning and Memory Task (AVLT):Presented below is Table 2, which

illustrates the values of Mean, Standard deviation, t-value, significance level, percentile and impairment

level on Immediate Recall on the 5 Auditory Verbal-List Learning Trials of Somatization Patients and

Normal Subjects


10/21



www.ijars.in


Table 2: The mean values of immediate recall on the 5 auditory verbal-list learning trials of somatization

patients and normal subjects.

Auditory Verbal-List

Learning

Study

Groups

Performance on Learning Trials

Immediate Recall

(no. of words

recalled and relearnt)

Normals

Average words recalled on each trials Deficit/

Non deficit

1 2 3 4 5 Percentile scores Across the trials

10 11 11 12 12.5 85t

-90t,

60th-75th,

25th

-40th

,

30th

,20th-30

th

respectively

No

Patients

Average words recalled on each trials Deficit/

Non deficit

1 2 3 4 5 Percentile score Across the trials

7 8 8.5 9 9.5 40 -50 ,

5th-15

th,

below 5th

,

below 5th

,

below 5th

Yes

Immediate Recall of 5 Trials on AVLT Task:On the basis of Table 2 , given above the results illustrate thaton the subdomains of immediate recall, the patients of Somatization Disorder performed inadequately, with

an average recall of 7 words in Firststtrial, 8 words in the Second trial, 9 words in the Third trial,8.5 words

in the Fourth trail and 9.5 words in the Fifth trial, in comparison to normal subjects whose immediate recall

was much greater with an average recall of 10 words in Firststtrial, 11 words in the Second trial, 11 words

in the Third trial,12words in the Fourth trail and 12.5 words in the Fifth trial. Correspondingly the

percentile scores obtained by the patient group from trials First to Fifth were 40 -50th

,5 -15th,below


11/21



www.ijars.in


5th

,below 5th,and below 5

th respectively. And the percentile score obtained by the normal subject group

from trials First to Fifth were 85th

- 90th, 60

th- 75

th, 25

th- 40

th, 30

th, and 25- 30

threspectively. The percentile

scores obtained by the patient group are indicative of significant immediate recall and relearning deficits in

Somatization Disorder.Results on total learning, delayed recall, long term percentage retention and recognition on AVLT:Table 3

presented below is Table 3, illustrates the values of Mean, Standard deviation, t -value, significance level,

percentile and impairment level on the Sub-Dimension of total learning, delayed recall, long term

percentage retention and recognition on Auditory Verbal-List Learning of Somatization patients and

normal controls.

Table 3: Illustrates the values of mean and standard deviation on the sub-dimension of auditory verbal-list

learning of somatization patients and normal controls.

S

No.

Auditory Verbal

List Learning

Study

Groups MeanStandard

Deviation

t

valueSignificance

Level

Percentile

score

Deficit/Non

deficit

1. Total LearningScore over 5 trials(No. of words

recalled over 5

trials)

Normals 51.3 2.0

4.0 **

25t-30

t No

Patients 41.3 9.0 Below 5 Yes

2. Long TermPercentageRetention

(Total no. of words)

Normals 107 5.2

2.9 **

85 No

Patients 81.6 31.7 5-10 Yes

3. Delayed Recall(Total no. of words)

Normals 11 1.6

3 **

15 -20 No

Patients 8 3.2 5 Yes

4. RecognitionHits

Normals 14.3 0.26

1.2 NS

15 -20 No

Patients 12 1.6 Below 5 Yes

*Significant at 0.05 **Significant at 0.01 NS is not significant

Total Learning Measure on AVLT task: On the basis of Table 3, presented above subsequently the totallearning score was calculated to see the final gain in the subjects learning after five trials. Table 3 shown

above, represents the obtained results on total learning which refers to the amount of new information the

subject is able to learn over a period of time. On this sub domain the groups were found to differ

significantly and the t-values was found to be 4. Also, the patients of Somatization Disorder differed with the

normal subjects on the basis of the obtained means (mean of normal subjects was 51.3 and that of patient

group was 41.3). The percentile scores obtained by the normal subjects was 25th-30

thand the patient group


12/21



www.ijars.in


was less than 5th

respectively which were suggestive of cognitive deficits in the patient group on the

subdomain of total learning.

The Long Term Percentage Retention on AVLT Task:Table 3 given above demonstrates the results on the

long term percentage retention task in which the subjects of the Somatization group differed significantly

from the normal subjects group (t-value came out to be 2.9). Another significant finding obtained on this

measure is that patients of Somatization Disorder differed with the normal subjects group on the basis of the

means obtained (mean of normal subjects group was 107 and that of the patient group was 81.6). The

percentile scores obtained by the normal subjects and the patient group were 85thand 5

th-10

th respectively

which were suggestive of deficits in Long Term Percentage Retention in the patient group.

Delayed Recall on AVLT Task:Table 3, given above, illustrates the results on Delayed Recall Test, which

suggests that there are significant differences between the groups i.e. t -value was 3. The data obtained on this

measure also indicates that patients of Somatization Disorder marginally differ with the control group on the

basis of the means obtained (mean of normal controls was 11 and that of patient group was 8 ). The

percentile scores obtained by the normal subjects and the patient group were 15th-20

thand 5

th respectively

which were suggestive of deficits in Delayed Recall in the patient group.

Recognition on AVLT task:Recognition refers to the identification of something as having been previously

seen, heard, and known. In the present study, as per Table 3, given above, the two groups did not differ

significantly on recognition test (t-value came out to be 1.2). Another significant finding that can be derived

out of the data obtained on this measure is, that patients of Somatization Disorder did not differ from the

normal subject group on the basis of the means obtained (mean of normal subjects was 14.3 and that of

patient group was 12 ). However, the percentile scores obtained by the normal subjects and the patient groupwere 15

th-20

th and below 5

th respectively which were suggestive of deficits in recognition, found in the

Somatization patients.

Results of Learning and Memory of meaningful passage:Presented below is Table 4, which illustrates the

values of Mean, Standard deviation, t-value, significance level, percentile and impairment level on

immediate and delayed recall of logical learning memory task.


13/21


14/21



www.ijars.in


60th

respectively which were not suggestive of any cognitive deficits in Delayed Recall test of Logical

Memory.

In conclusion the review of results obtained in the present study indicate that significant cognitive deficits

were found in the Somatization patient group in comparison to normal controls on the subdomains of

attentional measures assessed namely, Sustained Attention, Divided Attention, and also on measures of

verbal learning and memory namely, Immediate Learning of a list of words, Total Learning a list of words,

Long Term Percentage Retention a list of words, Delayed Recall in list learning, and Recognition in List

Learning. No significant deficits were found on the subdomains of Focused Attention, Immediate Recall of

Logical Memory and Delayed Recall of Logical Memory.

Henceforth, as per the results of present research, the hypothesis 1 has thus been partially supported by the

findings in the present research. The hypotheses 2, 3,4,5,6 thus been supported by the findings in the present

research. And hypothesis 7, 8 has not been supported by the findings in the present research.

V. THE DISCUSSION

Clinical Neuropsychology combines the knowledge base developed through classical, neurology with the

modern methods of American psychometric psychology. Clinical neuropsychological assessment in

psychiatric disorders details with the behavioural expression of brain dysfunction and with the practical

problem of identification, assessment, psychosocial rehabilitation in patients with cognitive impairments.

Among the various psychiatric disorders, Somatoform Disorders, and more specifically Somatization

Disorder lies abundantly however inadequately explored with regard to its specific cognitive features and

neuropsychological manifestations which may indefinitely contribute to lower socio-occupational

functioning in them.

Considering the lacunas seen in the existing body of research, the aim of the present study was to assess the

patients of Somatization Disorder in comparison to normal subjects on basic cognitive functions like

Attention, Verbal Learning and Memory. The central premise that the present study explored is, whether

Somatization Disorder is associated with significant attention and learning and memory deficits that

represent as the basic lower level information processing units. The present study made one of the novel

attempts to identify etiological and remedial possibilities for any lower level cognitive problems of

Attention, Verbal Learning and Memory, using a deficit measurement paradigm of neuropsychological

assessment. Presented below are the domain wise results of the present investigation.

On the measures of attention:The Cognitive processing models have proposed that attentional processes

comprise of, vigilance, selection, dual-task performance and automaticity. More recently, several

components of attention like (a) deployment of attention, (b) capacity, (c) resistance to interference, and (d)

mental manipulation have been identified (Mapau, 1995). The findings of present study suggest that

although patients with Somatization Disorder perform adequately in tasks of Focused Attention, nevertheless

they seem to present with noteworthy cognitive deficits on the subdomains ofattentional measures, namely


15/21



www.ijars.in


Sustained Attention, Divided Attention. This is suggestive of significant difficulties that may contribute to

socio-occupational dysfunction in such patients since they are likely to face difficulties in attend to a task in

hand for a required period of time, to direct attention using covert cues, shifting and switching attention from

one thing to the other, ability to attend to two or more tasks simultaneously and limitations in mentalflexibility. The later findings are also supported by studies of Ludwig (1972), and Flor-Henry Fromm-Auch,

Tapper, Schopflocher (1981) who suggest that patients with Somatization Disorder experience significant

deficits in complex attentional tasks, are slower in attentional tasks, in sustained vigilance tasks and

associated with impaired anterior control of attention (Niemi, Portini, Aalto, Hakala and Karlsson, 2002), in

concentration (Trivedi, Sharma, Singh, Tandon, 2005). The results of the present study can also be explained

using the model of attention (DeGangi and Porges, 1990), in the light of which the findings of this study

illustrate that patients with Somatization Disorder have significant deficits in attention holding which refers

to the ability to " the maintenance of attention, reach closure, when a stimulus is intricate or novel and

attention releasing which refers to the ability to turn off attention , shift from a stimulus , although have

no difficulty in attention getting which refers to "initial orientation or alerting to a stimulus." Also, another

interpretation as per divided attention model (Kahneman, 1973), urges that such patients are likely to have

limited amount of internal resources and capacity available to conduct tasks simultaneously.

On the measure of verbal list learning and memory:Learning and memory are capacities by which a person

is able to gain experience and retain it. Learning is the means of acquiring new information about the

environment and memory is the process of retaining it. Verbal learning and memory is the capacity to learn

and remember verbal material-tested through learning and recall of word lists and passages. It has been

hypothesized that the prefrontal cortex is important for the organization of material, recall, heuristic

strategies of learning, while the hippocampal structures are important for associates between time and space.

The Anterior areas of temporal lobe are responsible for verbal conceptual knowledge organization .Any

Lesions in left temporal lobe disrupts verbal memory and whereas, lesions in right temporal lobe disrupt

visual-spatial memory. The findings of present study suggest that patients of Somatization Disorder in the

present study show deficits in all measures of auditory-verbal list learning, namely, Immediate Learning of a

list of words, Total Learning a list of words, Long Term Percentage Retention a list of words, Delayed

Recall in list learning, and Recognition in List Learning. Hence the results of this study illustrate that such

patients have difficulties in Immediate memory which is the first stage of short-term memory storage that

temporarily holds information retained from the registration process, in long term retention storage and

delayed recall and recognition which is the retrieval of verbal auditory information after a short delay or

process or manipulate it mentally to solve cognitive and behavioural tasks. Deficits in all of the lattermentioned abilities, restricts the overall grasping, cue-learning and relearning ability of the these group of

patients, that may significantly contribute to many other cognitive tasks, such as judging, decision making,

reasoning, higher information processing and understanding. The findings highlighted by the present study

are supported by studies reported by Trivedi, Sharma, Singh, Tandon (2005), in Somatization Disorder

documenting that they frequently report decreased memory for recent events, impaired working memory,

and poor word-finding abilities. Additionally,Niemi, Portini, Aalto, Hakala, Karlsson (2002), report that


16/21



www.ijars.in


patients with Somatization Disorder, when compared to control subjects have been found to have

deficiencies in tests involving semantic memory, verbal episodic memory, with most notable impairments in

verbal memory and working memory. Thus, the findings in the present study that suggest retrieval failure in

the performance of the Somatization Disorder patient group can be explained by at least four reasons.Firstly, the Interference theory which states that, we forget not because memories are lost from storage but

because other information gets in the way of what we want to remember. Secondly, from the standpoint of

the Decay Theory, which states that when something new is learned, a neurochemical memory trace is

formed, but over time this chemical trail tends to disintegrate. Thirdly, Motivated forgetting, which occurs

when people want to forget something is common when a memory becomes painful or anxiety laden, as in

the case of emotional traumas such as rape and physical abuse. Lastly, According to the Retrieval Failure

Theory of Forgetting, forgetting is caused by the inability to access information that is represented in

memory. It could occur due to non-availability of the information represent in memory or inaccessibility of

the available information that can be retrieved at a specific time/place. Furthermore, The Generate Edit

Theory that emphasizes on the impaired ability to generate/guide/use retrieval cues used to generate

associates offers an alternative explanation for the latter deficits in individuals.

On the measure of logical learning and memory of meaningful passages:Logical memory refers to learning,

retention and retrieval of a meaningful passage with 21 facts is assessed in this study. It tests a good amount

of association learning and memory. The findings of present study suggest that although such patients

perform satisfactorily in tasks of logical memory, in both immediate and delayed recall. This suggest that

probably when storage and retrieval of information in the memory systems appears to take place according

to principles of associations, these patients do as well as normal control, however they may recollect and

demonstrate other kinds of biased recall of primed or threatening materials as well . The findings of the

present study are partially supported by evidences from Pauli and Alpers (2002), on Memory bias in

patients with somatoform disorders, and Merkel (2003), who points out that Somatization, has been

associated with certain psychological features like excessive distractibility, inability to habituate,

impressionistic cognitive schema, partial or circumscribed associations, and lack of selectivity.

Overall the results highlight that significant cognitive deficits were found in the Somatization patient group

in comparison to normal controls on the subdomains of attentional measures assessed namely, Sustained

Attention, Divided Attention, and also on measures of verbal learning and memory namely, Immediate

Learning of a list of words, Total Learning a list of words, Long Term Percentage Retention a list of words,

Delayed Recall in list learning, and Recognition in List Learning. No significant deficits were found on the

subdomains of Focused Attention, Immediate Recall of Logical Memory and Delayed Recall of LogicalMemory. The findings of this study contribute towards literature on cognitive deficits in psychiatric

disorders and raise consideration towards the specific deficits in attention, verbal learning and memory in

male patients with Somatization Disorder and their possible prognostic implications like greater functional

impairment and socio-occupational dysfunction in such cases. These findings are in conjunction and with

existing neuropsychological research evidences from studies conducted by Ludwig (1972), Flor-Henry,

Fromm-Auch, Tapper, Schopflocher (1981), Rief (1999),Niemi, Portini, Aalto, Hakala, Karlsson (2002),


17/21



www.ijars.in


Pauli, Alpers (2002), Merkel (2003), Trivedi, Sharma, Singh, Tandon (2005), who have all also emphasized

similar deficits in patients of Somatization Disorder.

Prognostically, the implications of the present study are that it contributes towards documentation of

preserved functions-the patients behavioural competencies and strengths. The researcher in this study

highlights the need and the obligation that the mental health professionals have towards the patient and the

caregivers to identify and report preserved abilities and behavioural potentials even when the assessment is

focused on delineating psychological dysfunction and making diagnostic discrimination. The evidences

available from the present study emphasis on the possible and neglected effects of impairments in attention,

verbal learning and memory in Somatization Disorder, which has effects on the persons everyday life

activities. Such deficits may significantly lead to restrictions in participation and define the nature and extent

of a persons involvement in life situations in relation to the impairments, activity limitations, health

conditions and contextual factors. It also refers to social participation and social disadvantages to

community, civic, leisure, work life that directly arise from cognitive deficits and the functional impairmentsin patients with Somatization Disorder.

The results of the present study need to be tempered with some caution as there are limitations of the

restricted sample size, recruited of number of cases which has had a time bound criteria this the current

study, short study period of this research, restrictions of sample selection in which only male patients,

belonging to particular ages, socio-economic and educational background have been included in this study.

Additionally other varieties of somatoform disorders, chronic cases of Somatization Disorder and those with

other co-morbidities, or on regular medications have been excluded from participating in this study. There

have been shortcoming in the inherent nature, selection of the neuropsychological tests as well, like we have

studied selective aspects of cognitive functions namely, attention, verbal learning and memory and excludedstudying other facets of cognition, information processing contributing towards an incomplete

neuropsychological profile of only lower order basic cognitive abilities in Somatization Disorder. There are

limits to the way in which facets of focused attention have been assessed, and the pre-established cut-off

scores, sensitivity and specificity of the neuropsychometric tests/tools used for assessment of cognitive

impairments in the present study. Additionally the present research did not in-cooperate any collateral

measure to assess functional impairment in Somatization patients and so raises only a possibility towards the

extent to which severity in attention and verbal learning and memory abilities can lead to functional

impairment in Somatization Disorder. Henceforth, the research findings revealed in this study are

preliminary in nature and constrained in generalizability.

VI. THE CONCLUSION

In conclusion, in consideration of the limitations and confines within which the results derived from the

current study are applicable, the authors suggests that future researches should overcome the above

mentioned limitations, utilizing a better study design, and carry out research comparing all the subtypes of


18/21



www.ijars.in


Somatoform disorders, on larger samples, over longer time periods to ascertain nature, stability, pattern and

trajectories of cognitive functioning over time, in Somatoform Disorders.

References:

1. Almgren, N. (1978). A retrospective study of operationally defined hysterics. British Journal of

Psychiatry, 132, 6773.

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th

ed.). Arlington, VA: American Psychiatric Publishing.

3. Bagadia V.N., Shastri P.C., Shah L.P. (1973).Hysteria-a prospective study of demographic factors of

192 cases. Indian Journal of Psychiatry,15,179-86.

4. Barsky A.J. (1992) Amplification, somatization, and the somatoform disorders.Psychosomatics, 33,

28-34.

5. Burton, C. (2003) Beyond somatisation: a review of the understanding and treatment of medically

unexplained physical symptoms (MUPS). British Journal of General Practice, 53,231-239.

6. Callahan C.D., Johnstone B (1994) The clinical utility of the Rey Auditory-Verbal Learning Test in

medical rehabilitation. Journal of Clinical Psychology in Medical Settings. 1(3), 261-268.

7. DasGupta, J. (2003) A study to examine the validity of tests of attention, learning and memory.

MPhil Clinical Psychology. Submitted to NIMHANS (Deemed University, Bangalore)

8.

DElisa L.F.,Satz P.,Uchiyama C.L., White T.(1996).Color trails test.U.S.A, Psychological

Assessment Resources Inc.

9. Dugbartey A.T., Townes B.D., Mahurin R.K. (2000) Equivalence of the Color Trails Test and Trail

Making Test in nonnative English-speakers. Archives of Clinical Neuropsychology,15(5),425-31.

10.Elkin-Frankstona S., Lebowitza B K., Lissa R., Kapusta B., Hollisa A.M., OConnora M.G. (2007)

The use of the Color Trails Test in the assessment of driver competence: Preliminary report of a

culture-fair instrument. Archives of Clinical Neuropsychology ,22( 5),63163.

11.

Fernandes Malloy-Diniz L; Antunes Parreira Lasmar V., Rabelo Gazinelli L.S.,Fuentes, D., SalgadoJ.V. (2007).The Rey Auditory-Verbal Learning Test: applicability for the Brazilian elderly

population. Revista Brasileira de Psiquiatria ,29,4.

12.Fink, P. (1996). From hysteria to Somatization: A historical perspective. Nordon Journal of

Psychiatry,50, 353-363.


19/21



www.ijars.in


13.Fink, P. (2005). Classification of Somatization and functional somatic symptoms in primary care.

Australian Journal of Psychiatry, 39, 772-781.

14.Flor-Henry, P., Fromm-Auch, D., Tapper, M., Schopflocher, D. (1981). A neuropsychological study

of the stable syndrome of hysteria. Biological Psychiatry,16, 687-626.

15.Ganguli I.H. (2000) Epidemiological findings on prevalence of mental disorders in India. Indian

Journal of Psychiatry,42, 14-20.

16.Garcia-Campayo J., Larrubia J., Lobo A., Perez-Echeverria M., Campos R. (1997) Attribution in

somatizers: stability and relationship to outcome at 1-year follow-up. Acta Psychiatrica

Scandinavica, 95, 433-438.

17.Garcia-Campayo J., Lobo A., Perez-Echeverria M.J., Campos R. (1998) Three forms of somatization

presenting in primary care settings in Spain. Journal of Nervous and Mental Diseases, 186,554.

18.Garcia-Campayo, J., Sanz-Carrillo, C., Baringo, T. (2001). SPECT scan in Somatization disorder

patients: An exploratory study of eleven cases. Australian and New Zealand Journal of Psychiatry,

35, 359363.

19.Goldberg, D., & Williams, P.(1988). A users guide to the General Health Questionnaire. Windsor,

UK: NFER-Nelson

20.Hakala, M .(2008) Brain imaging studies in severe somatization. Department of Psychiatry,

University of Turku, Finland. Annales Universitatis Turkuensis Sarjaser.

21.Kar B.R., Rao S.L., Chandramouli B.A., Thennarasu K. (2004) The NIMHANS Neuropsychology

Battery for Children - Manual, National Institute of Mental Health and Neurosciences (Deemed

University), Bangalore (2004)

22.Kolur, US., Reddy, Y.C., John, P., Kandavel, T., Jain, S. (2006). Sustained attention and executive

functions in euthymic young people with bipolar disorder. British Journal of Psychiatry, 189, 453-

458.

23.Lane, R.D. & Schwartz, G.E. (1987). Levels of emotional awareness: A cognitive developmental

theory and its application to psychopathology. American Journal of Psychiatry, 144, 133-143.

24.Lezak, M.D. (1995). Neuropsychological assessment (3rd eds.). New York: Oxford University Press

25.Lipowski Z. Somatization: the concept and its clinical applications. American Journal of

Psychiatry,1988, 145, 1358-1368.


20/21



www.ijars.in


26.Lipsanen T., Saarijarvi., Lauerma H. (2004) Exploring the relations between depression,

somatization, dissociation and alexithymia--overlapping or independent constructs? Psychopathology

37, 200-206.

27.Ludwig, A. (1972) .Hysteria: a neurobiological theory. Archives of General Psychiatry, 27, 771-786.

28.Maj.M., Satz, P., Janssen R.,Zaudig M., Starace F., DElisa L F., Sughondhabirom B., Mussa M.,

Naber D., Ndetei D., Schultz G., Sartorius N. (1994). WHO Neuropsychiatric Aids study, cross

sectional phase II: Neuropsychological and neurological findings. Archives of General Psychiatry,

51,51-61.

29.Matlin, M.W. (1983). Cognition, Holt, Renehart and Winston Inc. New York

30.Mukundan C.R., Narayan Reddy G.N., Hegde A.S., Jayanthi S., Kaliaperumal V.G. (1987).

Neuropsychological and clinical recovery in patients with head trauma. NIMHANS journal,5,23-32.

31.Niemi P.M., Portini R., Aalto S., Hakala M., Karlsson H.(2002). Cognitive functioning in severe

Somatization a pilot study. Acta Psychiatry Scandinavia, 106,461463.

32.Ott, R., Spielberg, R., Scholz, O.B. (2000). Somatoform disorders and implicit memory bias. German

Journal of Psychiatry [Online], 3.

33.Pershad, D. & Wig, N.N. (1994). PGI memory scale revised manual, Post Graduate Institute of

Medical Research, Chandigarh

34.

Rao, S. L., Subbakrishna, D. K.,Gopukumar, K. (2004) NIMHANS Neuropsychology Battery 2004. Bangalore: NIMHANS Publications.

35.Rief ,W., & Nanke, A.(1998). Somatization disorder from a cognitive-psychobiological perspective.

Current Opinion in Psychiatry, 12, 733-738.

36.Schmidt M (1996) Rey Auditory and Verbal Learning Test. A handbook. Los Angeles: Western

Psychological Services.

37.Serra, L., Fadda, L., Buccione, I., Caltagirone, C., Carlesimo, G. ( 2007). A Psychogenic and Organic

amnesia: A multidimensional assessment of clinical, neuroradiological, neuropsychological and

psychopathological features. Behavioural neurology; 18(1), 53-64.

38.Shapiro, D. (1965).Neurotic Styles. New York. Basic Books.

39.Singh G. (1968) A clinical-psychological study of 'hysteria'. Indian Journal of Psychiatry,10, 84-90.


21/21



www.ijars.in

40.Trivedi, J.K., Sharma S., Singh P.K., Tandon R. (2005). Neurocognitive functions in patients of

somatoform disorder. Poster presentation at VIII World Congress of Biological Psychiatry, 28 ,

Vienna, Austria.

41.Vyas JN., & Bharadwaj P.K. (1977) A study of hysteria-an analysis of 304 patients. Indian Journal of

Psychiatry,19,71-4.

42.World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders:

Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization

attention,verbal learning and memory deficits in somatization disorder

Documents