Address For correspondence: 1 Clinical Psychologist and PhD Scholar, Department of Psychiatry, Kasturba Medical College, Manipal University, Manipal, Karnataka. 2 Assistant 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 tests from 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
ansha_patel@yahoo.co.in *Corresponding author E-mail Id International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 2
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 Disorder carried 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 "medically unsolved 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 and control 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; International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 3
Barsky (1992) urged that they suffer from somatosensory amplification; Lipsanen , Saarijarvi and Lauerma (2004) have proposed that alexithymia is observed in them, and lastly Burton (2003), reports that misattribution and misinterpretation is a persistent findings in subjects diagnosed with Somatization Disorder. In deduction, the existing body of research sufficiently displays that Somatoform Disorder includes a range of not only somatic, psychopathological but also cognitive and neuropsychological symptoms. Such enduring cognitive deficits in Somatization Disorder provide a challenge to future research, as well as to clinical diagnosis and treatment. Among the various deficits, attention, learning and memory are among the less investigated, lower level cognitive functions upon which other higher mental abilities like, problem solving, reasoning and making judgments, symbol manipulation, behavioural reactions, and language largely rely on. The level of intactness and exactness of attentional, learning and memory abilities also determines the daily socio-occupational functioning of the individual, as hypothesized in light of the existing literature reviews.Thus, the present study, attempts to study the pattern of basic lower cognitive abilities like attention, learning and memory deficits in patients diagnosed with Somatization Disorder versus a group of normal subjects. Moreover, since the disorder has thus been shown to prevail and studied more often in females (Singh, 1968, Vyas and Bharadwaj (1977) and Bagadia , Shastri, Shah (1973), the present study endeavours to study the disorder in male population, Therefore, the present study aims to investigate attention, learning and memory deficits in male patients with Somatization Disorder in comparison to age-education, background matched normal controls. The objectives of the research were to assess and examine aspects of attention, verbal learning and memory of patients with Somatization Disorder vs. normal subjects. II. HYPOTHESES: Based on the above mentioned objective, the hypotheses were as follows: 1. There will be significant differences in Focused, Sustained and Divided Attention of patients with Somatization Disorder and normal subjects. 2. There will be significant differences in Immediate Recall of Auditory Verbal Learning Test in patients with Somatization Disorder and normal subjects. 3. There will be significant differences in Total Learning of Auditory Verbal Learning Test in patients with Somatization Disorder and normal subjects. 4. There will be significant differences in Long Term Percentage Retention of Auditory Verbal Learning Test in patients with Somatization Disorder and normal subjects. 5. There will be significant differences in Delayed Recall of Auditory Verbal Learning Test in patients with Somatization Disorder and normal subjects. 6. There will be significant differences in Recognition of Auditory Verbal Learning Test in patients with Somatization Disorder and normal subjects. 7. There will be significant differences in Immediate Recall of Logical Memory Test in patients with Somatization Disorder and normal subjects. International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 4
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 known acquaintances, 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 up till 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. International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 5
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 ages of 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 of Attention-focused, Sustained and divided, Verbal Learning and memory and Logical Memory. Attention, Verbal Learning and Memory 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 by Kolur, 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 International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 6
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 using two 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 Rey Auditory 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 authorities concerned 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 International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 7
assessments was approximately 2 hours and the testing was done in the morning between 8am to 1pm. After data collected and compilation, it was subjected to statistical analysis. The Statistical analysis: The totals scores obtained on each subdomain of the various attention and verbal learning and memory assessments from the patient and normal control group were compared using the students t test for significance of mean difference among the obtained total scores on each measure. The p value of <0.05 or <0.01 was considered to be statistically significant. The percentile scores corresponding to the test scores as per the norms in the Nimhans Neuro-psychological Battery Manual (Rao, Subbakrishna, and Gopukumar, 2004) were also analysed to ascertain whether they fall in deficit category or not. IV. RESULTS The preliminary results of socio-demographic data gathered from this study suggested that the two study groups in this study did not differ significantly on socio demographic variables. The results section summarized below includes a tabular representation of the data that has been subjected to statistical analysis. It provides an overview of the Mean and Standard deviations of patients of the two study groups i.e. Somatization Disorder and age, SES, education matched normal subjects, on the measures of Attention, Verbal Learning and Memory. Students-t for independent samples was used to test the significance of mean difference obtained by the two study groups and these values were checked for significance at two levels, namely 0.05 and 0.01. Also, this section presents the percentile scores of the study groups on sub domains of Attention, Verbal Learning and Memory was mentioned, in order to highlight the adequacy of performance and the cognitive deficits found in the study groups. Attention Measures: Presented below is Table 1, which illustrates 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.
International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 8
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 Groups
Mean
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
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 International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 9
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 suggestive of any deficits in any of the study group, as the patients of Somatization Disorder obtained a percentile score of 65 th -68 th 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 78 th -84 th on the focused attention task part-2, in comparison to normal subjects group who obtained a percentile score of 97 th -100 th . 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 10 th - 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 3 rd in comparison to the normal subjects who had a percentile score of 66 th -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 International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 10
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 2 33 3 4 5 Percentile scores Across the trials 10 11 11 12 12.5
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 th -50 th , 5 th -15 th , below 5 th , below 5 th , below 5 th
Yes
Immediate Recall of 5 Trials on AVLT Task: On the basis of Table 2 , given above the results illustrate that on the subdomains of immediate recall, the patients of Somatization Disorder performed inadequately, with an average recall of 7 words in First st trial, 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 First st trial, 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 -50 th ,5 -15 th ,below International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 11
5 th ,below 5 th ,and below 5 th respectively. And the percentile score obtained by the normal subject group from trials First to Fifth were 85 th - 90 th , 60 th - 75 th , 25 th - 40 th , 30 th , and 25- 30 th respectively. 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 Mean Standard Deviation t value
Significance Level Percentile score Deficit/Non deficit 1. Total Learning Score over 5 trials (No. of words recalled over 5 trials) Normals 51.3 2.0 4.0
** 25 th -30 th No Patients 41.3 9.0 Below 5 th Yes 2. Long Term Percentage Retention (Total no. of words) Normals 107 5.2 2.9
NS 15 th -20 th No Patients 12 1.6 Below 5 th 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 total learning 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 25 th -30 th and the patient group International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 12
was less than 5 th 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 85 th and 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 15 th -20 th and 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 group were 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.
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Table 4: Illustrates the values of mean and standard deviation on the sub dimension of logical memory of somatization patients and normal subjects S No Dimensions Of Logical Memory Study Groups Mean
Standard Deviation
t-value Significance level Percentile score Deficit/ non deficit 1. Logical memory Immediate recall (total words recalled) Normals 15.6
2.4
0.14
NS
50 th -60 th No Patients 15.5 1.5 50 th -60 th No 2. Logical memory Delayed recall (total words recalled)
Normals 18.9 2.7
2.05
* 70 th -75 th No Patients 16.3 2.7 50 th -60 th No *Significant at 0.05 **Significant at 0.01 NS is not significant Logical memory task, immediate recall subtest: The Logical memory is assessed by the immediate and delayed recall of a meaningful passage. Table 4, shown above, illustrates the results found on logical memory. It was found that on the dimension of logical memory, immediate recall trial the t-value was insignificant i.e. it was 0.14. Patients of Somatization Disorder were similar in performance as the normal subjects. Patients of Somatization Disorder secured an percentile score of 50 th -60 th in comparison to normal subjects who also had an percentile score of 50 th -60 th on immediate recall trial. Another significant finding that can be derived out of the data obtained on this measure is, that patients of Somatization Disorder did not differ with the control group on the basis of the means obtained (mean of normal subjects was 15.6 and that of patient group was 15.5). There were no significant cognitive deficits found in the study groups on this measure. Logical memory task: Delayed Recall subtest: On the dimension of logical memory, delayed recall trial as per Table 4, given above, the t-value was found to be significant, i.e. it was 2.05. Patients of Somatization Disorder did poorly than the normal subjects. The patients of Somatization Disorder differed with the control group on the basis of the means obtained (mean of normal subjects was 18.9 and that of patient group was 16.3). The percentile scores obtained by the normal subjects and the patient group were 70 th -75 th and 50 th - International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 14
60 th 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 impairment s. 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 of attentional measures, namely International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 15
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 mental flexibility. 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 latter mentioned 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 International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 16
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 Logical Memory. 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), International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 17
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 impairments in 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 excluded studying 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 International Journal of Applied Research and Studies (iJARS) ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014) www.ijars.in Manuscript Id: iJARS/895 18
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