The patient is a 31-year-old, single female attorney, who was referred by her primary care physician for somatic complaints that have been worked up thoroughly, with normal results. In the past, she has been worried about and has pursued various diagnoses, including endometriosis, neurofibromatosis, and ovarian cancer, and has doctor-shopped when told her problems might be psychological in origin. Her primary care physician referred her to me for evaluation of possible somatization disorder.

This session occurred three years into a 4-session-per-week analysis. During my initial evaluation sessions, I learned that the patient has a history of fainting spells as an adolescent. At the time, her pediatrician pursued a workup that was negative for organic causes, but the doctor was fired by the parents after referring the patient to a psychiatrist. Of note, when she was a preschooler her mother contracted a rare tropical disease, and for a year of convalescence a widowed great aunt lived with the family to take care of my patient.

My provisional diagnosis was somatization disorder. I did not prescribe any medication for the patient, in part because there were no clear target symptoms to medicate, and in part because I felt medication was likely to feed into her wish to take on the sick role. Over time, I hypothesized that the rage she experienced towards her mother for neglecting her as a small child had become a source of guilt, which resulted in a wish to punish herself. She chose illness as the form of punishment because it served multiple functions: it allowed her to identify with her mother, to compete with her, and to feel worthy of the kind of sympathy and attention she had craved as a child. Since beginning analysis, the patient has been more willing to consider the possibility that she somaticizes, but in times of stress, she rapidly reverts to the belief that she has a fatal illness.

This session took place on a Thursday afternoon, her fourth session that week. She entered the office, hung up her coat, put down her bag, and lay on the couch without first making eye contact.

Pt: My boss is being such a bitch.

Me: What happened?

Pt: Just the usual. She doesn’t take me seriously. Sometimes I think she rolls her eyes when I come to her with questions.

(She is silent)

Pt: I know what you’re going to say about this, but I’ve been coughing and having hip pain again. You’ll say I’m somaticizing—sometimes I believe that, but sometimes I just don’t know. How can I ever really tell whether these symptoms are real?

I wonder about the transition between comments. Why does she go from complaining about her boss to talking about her somatic symptoms? My sense is that she associates her boss with her mother, and her anger at both of them is intertwined. But being angry at her mother makes her feel guilty and anxious, so to defend against these emotions she uses somatization, her accustomed mode of defense. And yet, she is beginning to be aware of this tendency, so she comments about it with some ability to self-observe.

I think that her key issue now is uncertainty. She has been developing insight into the fact that she fabricates her symptoms, but then, under stress, she doubts that insight. How does that doubt help her?

I know from prior sessions that she was angry at her mother. I wonder if her continued doubt about the reality of her symptoms is a way for her to tolerate her guilt about this anger: “I am angry, which means I am destructive and bad, so I deserve to be punished with a terrible illness; but perhaps there is justification for my anger towards my mother, in which case I don’t deserve to be punished. Still, I have no right to think that my mother (in the guise of her boss) is the one who is bad, because she is so ill, so I need to remain unsure.”

I have my own association to a memory of waiting two weeks for a lab result, to find out if I had a very serious illness (I didn’t). I think about how painful it was not to know, but how in some ways that state of doubt and anxiety was preferable to getting the result and potentially learning that something was really wrong.

I decide to pursue her feelings about certainty.

Me: There’s something important about keeping yourself in doubt about whether you are actually ill.

Pt: Why would I do that? It’s such an uncomfortable state to be in! It just makes me more anxious!

Her affect has intensified, which makes me think I chose the best course to pursue.

Me: With what thoughts?

(She pauses)

Pt: There was this game my aunt would play with me. I had this toy doctor kit, you know, with a plastic stethoscope. They got it for me when my mom got sick. I think they thought it would help me understand what was happening. So I would lie down on the sofa and pretend to be sick, and my aunt would do silly stuff with the toys, like listen to my foot with the stethoscope, and tap the hammer on my nose. And then suddenly, she would say, “All better!” and tickle me. And I would giggle and run away.

(She is silent)

I think there might be an association between her memory of lying on a “sofa” as a child and her lying on a couch during our sessions.

Pt: I don’t know why I thought of that. I guess it has something to do with being sick. Maybe with the idea that being sick is fun.

Me: And that your being sick is something silly that doesn’t need to be taken seriously.

Pt: Nah. My mom was the one who was really sick. And everyone needed to be quiet so we didn’t disturb her.

Me: But you were still in pain—you missed having your mom care for you.

Here I am probing to see if she is ready to acknowledge her anger toward her mother.

Pt: Yeah. I think they did care about me. That just wasn’t the kind of thing that got paid attention to. They meant well.

Me: And here you are, lying on another sofa, and wondering if I will take your concerns seriously.

She is beginning to gain insight into her tendency to somaticize, but is not yet ready to address the feelings driving it directly, especially anger. For this reason, I needed to pick up on the transference in her description of the game on the sofa, so those feelings could begin to play out with me. Assuming that this transference intensifies, I will be able to interpret these feelings and help her connect the dots between her anger and her physical symptoms.