Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76

DOI: 10.12740/APP/60532

Symptoms of cardiovascular diseases in the course

of mental disorders

Anna Ostachowska, Lech Popiołek, Jolanta Walczewska,

Krzysztof Rutkowski

Summary:
Psychosomatic disorders are extremely common in patients in non-psychiatric departments. It is widely known
that in these cases comorbid psychiatric disorders are highly prevalent and that the importance of psychoso-
cial factors is relevant. However, it is still a challenge for both internal medicine and mental health profession-
als to diagnose and treat them effectively. The need of evidence-based treatment guidelines for clinicians is
obvious. As far as it is concerned, DSM-5 has redefined the criteria of somatoform disorders, underlying the
importance of incorrect thoughts about symptoms whether organic ethiology.
Methods/Design: The aim was to provide an insight into the barriers of diagnosing psychosomatic disorders
in cardiology referring to possible psychiatric comorbidity. Over 150 actual abstracts and full text manuscripts
were checked. The literature published in English and Polish, mostly in PubMED/MEDLINE, PsycINFO, EM-
BASE, Cochrane Database of Systematic Reviews of past 10 years was studied and compared to the liter-
ature of psychoanalytic theory. Disscussion: It is worth to remember, that for high proportion of patients with
mental disorders somatic syndrome is the only symptom they report to physicians. Emotion regulation theo-
ry, alexithymia theory and desomatization and resomatization theory find it as the effect of unsolved problems
with emotions. Moreover, functional neuroimaging studies seem to reveal coherent findings. Based on it, the
neurophysilogical model of emotion regulation and the mechanism of cognitive-emotional executive control
were described. Accordingly, literature shows that in heart disease patients the incorporation of psychological
interventions in healing process significantly reduces mortality and relapse.

INTRODUCTION patients are accompanied by undiagnosed men-

tal health problems, which are often an impor-
In medical practice we often meet patients tant risk factor for serious somatic diseases. This
with somatic symptoms without organic cause. paper aims to draw attention to the symptoms of
This circumstance makes it necessary to think cardiovascular system dysfunctions which, em-
holistically, adding new areas of activity to the bedded in the context of psychopathology, will
diagnostic and therapeutic pathways of internal not only enable full diagnosis, but also an effec-
medicine. In many cases problems reported by tive treatment [1]. It presents the current state
of knowledge about psychosomatic symptoms.
Anna Ostachowska,1 Lech Popiołek,2 Jolanta Walczewska,3 Literature is full of vagueness and ambiguities
Krysztof Rutkowski2: 1Department of Adult, Child and Adolescent of terms related to the definition of psychoso-
Psychiatry, Kraków, Poland. 2Department of Psychotherapy, Jagiel- matic illnesses [2]. The very concept of somatiza-
lonian University Medical College, Kraków, Poland. 3Department of
Internal Medicine and Gerontology, Jagiellonian University Medical
tion, according to Wilhelm Steckel a psychoana-
College, Kraków, Poland. lyst who introduced this term, means a tenden-
Correspondence address: ostachowska.anna@gmail.com cy to being more aware of physical than men-
 Symptoms of cardiovascular diseases in the course of mental disorders 67

tal aspects of emotional states and expressing ter treatment with antidepressants. Faster heart
emotional suffering by means of somatic symp- rate and breathing, tremors, palpitations, short-
toms [3]. The ICD-10 lacks a separate diagnostic ness of breath, chest discomfort, dizziness, fear
category related to psychosomatic illnesses. This of death, are some of the functional symptoms of
term occurs primarily in relation to disorders in autonomic arousal and manifest themselves sim-
somatic form (ICD-10), and somatoform disor- ilarly to cardiovascular problems. They can oc-
ders (DSM-IV). Due to restrictive criteria, the cur in the course of social phobia, panic disorder,
categories capture only severe conditions. Rask specific phobias, as a part of an acute stress re-
et al. demonstrated in their study possible clin- action, in patients addicted to psychoactive sub-
ical benefits of the new category labelled ‚mul- stances, in conversion disorder or in alexithym-
tiple symptoms’, which was addressing sub- ic patients.
threshold categories of medically unexplained
symptoms (MUS) classified as somatoform dis-
order [4]. In DSM-5 several modifications in Psychosomatic syndromes in hospital emergency
this category have been done. In addition to the department, Primary Health Care and day hospital
changes in nomenclature, one of the most impor- for neurotic disorders treatment
tant changes is the lack of need to exclude organ-
ic cause to diagnose the somatoform disorder. Patients reporting symptoms without organic
More important is that somatic symptoms are cause of a disease are especially common in hos-
accompanied by inadequate thoughts, feelings pital emergency departments (HED) and prima-
and behaviors related to symptoms [5]. ry health care (PHC). The most common com-
Because of the inadequacy of the classic psy- plaint is pain in the chest. It may be a symptom
chiatric nosography for the concept of this kind of coronary artery disease or myocardial infarc-
of diseases, in 1995 The Diagnostic Criteria for tion, which is one of the most terrifying condi-
Psychosomatic Research (DCPR) were intro- tions for patients [7-8]. According to numerous
duced. This 12 „psychosomatic syndromes” pro- studies, in emergency departments the diagno-
vided operational tools for psychosocial varia- sis of organic cause of the ailment is excluded in
bles and its’ prognostic and therapeutic implica- 30% to 77% of patients [9-12]. A comparable pro-
tions in clinical settings. Eight syndromes con- portion of patients in primary health care, i.e. be-
cern the main manifestations of abnormal illness tween 22% and 58%, report somatic complaints
behavior (persistent somatization, functional so- that are not of organic nature [13]. Sobański et
matic symptoms secondary to a psychiatric dis- al. revealed that also 75% of patients admitted
order, conversion symptoms, anniversary reac- to the day hospital for neurotic disorders treat-
tion, disease phobia, thanatophobia, health anxi- ment submitted “pseudocardiac symptoms” of
ety, illness denial) and the other four syndromes tachycardia/palpitations and chest pain [14]. In
refer to the domain of psychological factors af- non-psychiatric units the diagnosis of the symp-
fecting medical conditions (alexithymia, type toms commonly ends at this point. Despite the
A behavior, demoralization, irritable mood). Sir- good prognosis, the presence of chest pain with
ri and Fava made the comparison of the DCPR, no evidence of organic heart disease frequently
DSM-IV and DSM-5 proposal. In their opinion causes withdrawal from social activities at a lev-
the 12 DCPR syndromes, being more sensitive, el comparable to patients suffering from coro-
may broaden the physician’s perspective on pa- nary artery disease [15]. It is known that mental
tients’ problems, capturing psychological vari- health problems themselves may trigger, main-
ables which do not find room in the customary tain, or even worsen pain in the chest [16]. Ex-
psychiatric classification [6]. clusion of organic cause of symptoms without
It is worth noting that besides the diagnoses explaining other possible causes, in many cas-
of psychosomatic disorders, symptoms local- es is not enough to reassure patients who are
ised in the body are characteristic for the diag- concerned about their health [17]. Even perform-
nosis of many other mental disorders. In masked ing diagnostic tests to rule out heart disease can
depression, the main complaint may be a prob- strengthen the patient’s belief in struggling with
lem with circulatory system that disappear af- a serious health problem [18]. In addition, anx-
Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76
68 Anna Ostachowska et al.

iety may be accompanied by reduced level of portant etiologic factor in the development and
quality of life (QoL), the incidence of consecu- prognosis of coronary artery disease (recom-
tive episodes of chest pain, overuse of health mendations I A). Loneliness, lack of social sup-
care [19] and withdrawal from social roles. It has port, death of a partner, similarly to depression,
been observed that in primary care patients who depressed mood, anxiety, hostility, or PTSD, are
reported more than five symptoms, increased an independent etiological factors of coronary
impairment of social roles occurred more fre- heart disease development. They have a nega-
quently when these symptoms had no medical tive impact on both the prognosis and the pres-
explanation than when they were results of or- ence of complications during treatment [28].
ganic dysfunctions [20]. These guidelines recommend to diagnose and
What is more, the study on the costs of soma- treat psychiatric disorders as a part of the pre-
tization in English population shows that only vention of coronary heart disease (I B). Numer-
mental health care service is the one that does ous reports support the aforementioned recom-
not show significantly increased rates of utiliza- mendations. Ashley M. Harris et al. observed
tion by somatizing patients [21]. We can assume that comorbidity of mental disorders in patients
that on the one hand this kind of patients tend without diagnosed organic disease who report
to ignore their mental ailments and communi- somatic symptoms is more than four times high-
cate their emotional states by somatic symp- er than in patients with organic diagnoses, and
toms, usually being misunderstood by physi- reaches 60% [29]. In another study, psychiatric
cians. On the other hand, mental health care ser- diagnosis was present in 75% of patients report-
vice seems to offer the most adequate treatment ing somatic symptoms with no evidence of or-
for them. ganic disease. Panic disorder was diagnosed in
Here it is worth to present the results of a half of the studied patients (47.1%), and de-
a study evaluating medical care and treatment pression in 21.4% of patients. Generalized anx-
in the newly established Medically Unexplained iety disorder and obsessive-compulsive disor-
Symptoms Clinic (MUS Clinic) in London [22]. ders were diagnosed in 5.7% of patients, and
The authors emphasize the fact that the vast less than 3% of patients were diagnosed with
majority of patients admitted to the diagnos- somatoform disorders. The most common com-
tics suffered primarily from previously unde- plaint in patients with generalized anxiety dis-
tected mental health disorders. Most often pa- order and panic disorders was the conviction of
tients were diagnosed with depression and anx- heart disease [30].
iety disorders, which implies two further issues. Moreover, anxiety disorders, depression, de-
One of them is the need to improve the efficien- pressed mood or loneliness separately, are an
cy of recognition of these disorders at primary important risk factors for cardiovascular diseas-
and secondary health care [23]. The second issue es. Due to the frequent comorbidity of mental
is related to diagnostic difficulties with clinical illness with cardiovascular diseases and worse
manifestations of depression and anxiety disor- prognosis for this coincidence, it is important to
ders, which could be restricted to somatic symp- extract mentally disturbed person from the pop-
toms [24, 25]. ulation of people suffering from cardiovascular
diseases. In accordance with current knowledge,
the assessment of mental functions is an impor-
Guidelines and treatment pathways tant element in the diagnostic and therapeutic
process in patients with cardiac symptoms, ir-
British guidelines for dealing with chest pain respective of diagnosis of organic heart disease.
of 2010 [26] does not recommend further pro- Another study suggests that understanding
ceedings based on the assumption that the mere the essence of reported complaints provides re-
recognition of the absence of organic heart dis- lief for patients and it may be an intervention
ease will improve the patient’s condition [27]. with positive therapeutic outcomes [27]. Unfor-
The current German guidelines regarding the tunately, as reported in studies, psychosomat-
psychosocial factors in cardiology (2013) include ic disorders are diagnosed too rarely in prima-
the area of psychosocial functioning as an im- ry care [31]. This situation has many causes [32],
Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76
 Symptoms of cardiovascular diseases in the course of mental disorders 69

among other things, it is doctor’s fear of over- of a panic attack. The explanation may be found
looking “serious illness” [7] and the lack of clear in a study by Bernard D. Beitman et al., where
diagnostic pathways. In ICD-10 and DSM-IV so- it has been noted that up to 32-41% of patients
matization disorder is diagnosed after the exclu- with anginal pain without coronary artery dis-
sion of organic cause, which often is very diffi- ease do not feel fear when experiencing a pan-
cult. The reports also highlight the lack of EBM ic attack [38].
(Evidence-based medicine) based guidelines Takotsubo cardiomyopathy – in other words
for the management of patients reporting med- stress-induced cardiomyopathy (Transient left
ical condition without organic explanation [33]. ventricular apical ballooning syndrome – TL-
In 2012, in Germany, for the first time, an inter- VABS) has the similarly transient nature of is-
disciplinary team of specialists in medicine and chemia. It is manifested by pain in the chest,
psychosocial sciences, together with a represent- shortness of breath, hypotension and changes in
ative of patients led to the drafting of guidelines ECG as in a myocardial infarction. The diagno-
for dealing with somatoform disorders. Innova- sis is based on 1) the presence of transient dys-
tions in this edition of the Guidelines include i.a. kinesia of left ventricular apex and the centre of
emphasis to features of the doctor-patient rela- the ventricle, comprising an area of vascularisa-
tionship important in the treatment of somato- tion of more than one coronary artery; 2) the lack
form disorders, taking into account also iatro- of significant coronary artery disease and lack
genic areas [34]. of angiographic characteristics of plaque rup-
ture; 3) new changes in ECG; and 4) the exclu-
sion of the presence of a pheochromocytoma or
Transient myocardial ischemia and stress-induced myocarditis. The described cardiomyopathy is
cardiomyopathy as psychosomatic syndromes associated with a good prognosis and with full
recovery in up to 4 weeks. Mortality varies be-
In 2012, carbon dioxide challenge test imitat- tween 0% and 8% [39]. It is estimated to occur in
ing panic attack triggering myocardial ischemia 0.02% of the population of the United States, of
was described. The experiment was conduct- which 89% are women, especially in postmen-
ed in a man with a long history of occurrence opausal period [40]. It is often comorbid with
of panic attacks in the course of agoraphobia. cerebrovascular diseases and psychiatric disor-
The study is important due to the fact that the ders, including anxiety disorders, mood disor-
impact of a panic attack on disturbances of my- ders, as well as with liver failure, sepsis and can-
ocardial perfusion in patients without structur- cer [41-42]. The exact mechanism of symptoms
al heart disease has been experimentally demon- is still unknown. It is believed that the symp-
strated for the first time. During the study, the toms of cardiomyopathy are the result of severe
patient reported mild chest pain, palpitations stress, which occurs due to the release of cat-
and dizziness. There has been an increase in echolamines. The excess of catecholamines af-
blood pressure to 190/100 mmHg and increased fects the modification of beta2-adrenergic recep-
heart rate, oxygen saturation remained at 98%. tors, leads to vasoconstriction, accumulation of
No ischemic changes were observed in ECG, toxic metabolites, and consequently blocks the
whereas single-photon emission tomography contractility of certain areas of the heart mus-
image demonstrated reversible myocardial is- cle. This thesis is confirmed by reports on occur-
chemia [35]. Currently it is known that different rence of cardiomyopathy, similar to that in Ta-
mechanisms are responsible for triggering pain kotsubo cardiomyopathy, in patients with a di-
in the chest during a panic attack [36]. The one agnosis of pheochromocytoma. In this case, re-
most often mentioned is hyperventilation which moval of the catecholamine-producing tumor
causes respiratory alkalosis. It is related to cal- results in left ventricular failure remission [43].
cium influx into the cells, which induces spasm Some authors also believe that the described car-
of coronary arteries resulting in myocardial is- diomyopathy has a protective function, which
chemia [37]. In the described case, despite over- allows a patient to survive a stressful situation
activity of the adrenergic system recorded dur- without permanent damage to the myocardi-
ing the test, the patient denied the occurrence um [44]. The researchers suggest that the same
Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76
70 Anna Ostachowska et al.

protective function is performed by dissociative the other, negative psychosocial conditions may
amnesia for the psyche. In people who have ex- promote unhealthy behavior [52].
perienced dissociative amnesia after traumatic The current review of studies [53] on the con-
events, the prevalence of posttraumatic stress tribution of depression in the global prevalence
disorder (PTSD) is lower [45] [46, 47]. In 2014, of coronary artery disease (CAD) suggests that
Amir Toussi et al. reported, for the first time, the risk of its development is increased in peo-
a case of a woman in whom Takotsubo cardio- ple with depression by 56%, and that depression
myopathy was accompanied by the occurrence is responsible for 2.95% of DALYs (Disability-ad-
of dissociative amnesia in reaction to her sister’s justed life year – years of life lost due to prema-
death [48]. The researchers suggest that dysreg- ture death or bodily injury resulting from trau-
ulation of glutamate levels in the blood and in- ma or disease) associated with CAD. Bacon et
creased levels of catecholamines might be the al. (2014) showed that patients diagnosed with
mechanism responsible for the occurrence of dis- an anxiety disorder are four times more likely to
sociation in the course of transition cardiomy- develop hypertension during one year of obser-
opathy [47, 49, 50]. Knowledge on the issue of vation. Contradictory information has been ob-
these interdependencies is still incomplete and tained in the study on the relationship between
requires further studies. depression and hypertension. In the meta-anal-
ysis of prospective studies, results suggest that
depression increases the incidence of hyperten-
Psychocardiology and the comorbidity sion by 42% [54]. On the other hand, the larg-
est prospective study on this issue, including
Bearing in mind the strong interdependen- 36,000 people, that is about 50% more than the
cies between heart diseases and mental health, entire meta-analysis, does not confirm these re-
a new field of science – psychocardiology – has sults. In follow-up examinations after 11 and 22
been created. Psychocardiology combines medi- years, the obtained results showed a combina-
cal thinking and psychology. It is impossible not tion of intensification of depressive symptoms
to mention that Poland is one of the first coun- with lower blood pressure [55, 56]. The expla-
tries which recognized the role of psychologi- nation for these discrepancies could be other re-
cal problems in patients with cardiovascular dis- ports suggesting that only affective symptoms of
eases. In 1961 prof. Zdzislaw Askanas opened depression impact the sympathetic nervous sys-
psychological laboratory at the Institute of Car- tem dysfunction. Somatic component and the to-
diology, Medical University of Warsaw, one of tal score on a scale of depression have no signif-
the first of its kind in Europe [51]. The benefi- icant influence [57].
cial effects of cooperation of cardiologists and
psychologists has been confirmed by the results
Mechanisms of symptoms
of meta-analysis of 43 studies on psychological
interventions in patients suffering from cardio- Regulation of emotions
vascular disorders. During the two year observa-
tion of patients with heart disease who simulta- Trying to understand how psychology af-
neously participated in psychological interven- fects somatics, it is impossible not to mention
tions, it has been shown that the mortality rate the concepts of diseases stemming from psy-
in this group decreased by 27% compared with choanalytic thinking. Some theorists believe
patients who were monitored only by an intern- that it is useless to distinguish psychosomatic
ist. Moreover, in the long perspective frequency illnesses from other diseases, as most somatic
of disease reoccurrence was lower by 43%. Re- disorders have mental aspect, as well as men-
searchers explain the relationship between car- tal illnesses have somatic aspect. They empha-
diology and psychology by common pathophys- size the fact of non-existence of simple cause
iologic and behavioral mechanisms. On the one and effect relation between the “‘psyche” and
hand psychologic factors may activate some neg- “soma” [58]. Aleksandrowicz also says that neu-
ative pathophysiologic metabolic pathways, on rosis and their psychotherapy are an integral
Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76
 Symptoms of cardiovascular diseases in the course of mental disorders 71

part of medicine and medical tasks and signif- tween primary alexithymia – a genetically deter-
icantly exceed outside the scope of psychiatry mined personality traits and secondary alexithy-
[59]. Such thinking is supported by the theory mia – which is a defense mechanism for experi-
of emotional regulation developed by Graeme enced trauma [74, 75].
J.Taylor [60], which does not distinguish organ- A study comparing the features of alexithymia
ic and functional, physical or mental diseases, in patients suffering from cardiovascular disor-
treating them as impaired regulation of various ders and mood disorders showed an increased
sub-systems of the body. In this approach, each overall level of alexithymia in both groups.
illness is psychosomatic, as they can be accom- Higher score in terms of poverty of imagina-
panied by both physiological and mental chang- tion and a lower emotional excitability have
es. Sigmund Freud presented a similar way of been observed among patients with cardiovas-
thinking over 120 years ago. In addition to the cular diseases. In contrast, more intense charac-
symptoms of conversion neurosis, of symbol- teristics – the difficulty in verbalizing emotional
ic significance, he mentioned actual neurosis experience and poor insight into own emotion-
whose bodily symptoms were the result of lim- al experience – have been observed in patients
ited capacity to cope with tension [61]. This the- with mood disorders. Dysregulation of auto-
ory seems to be confirmed by Kyung Bong Koh. nomic nervous system is considered to be the
In his study, based on 47 patients, he showed pathomechanism responsible for comorbidity
that suppression of anger was a predictor of so- of alexithymia and cardiovascular diseases [76].
matic symptoms [62]. Similarly, in patients after The gap between the intensity of the emotional
myocardial infarction, the intensification of so- response and recorded reaction of the autonom-
matization was associated with blocking the ex- ic nervous system, described in other publica-
pression of unpleasant emotions [63]. Liang Liu tions [77], has been also observed in the study
et al. showed that, the tendency to react with [78]. According to Henry Krystal, lack of access
anger, on the one hand, and excessive suppres- to conscious experiencing the affective content
sion, on the other, play an important role in the in alexithymic patients leads to its disclosure in
emergence of somatic symptoms in people with the body, i.e. somatization [2].
anxious-ambivalent attachment style. In this ap-
proach, the intervention directed to the ability
to express and cope with feelings, could reduce, Theory of the desomatization – resomatization
in some people, a tendency to present medical-
ly unexplained symptoms [13]. The occurrence of somatic symptoms without
organic cause related to illness is also explained
by the psychoanalytic concept of early trauma.
Alexithymia Krystal, explaining the genesis of psychosomat-
ic disorders, drew attention to the difficulties in
The term alexithymia is defined as difficulty diagnosis of emotional states arising from block-
in identifying and expressing emotions, pover- ing the processes of differentiation, verbalization
ty of imagination and externally-oriented way of and desomatization of child’s affect on the ba-
thinking [64]. Its relations with both mental ill- sis of deprivation of the child’s needs at an ear-
nesses and somatic diseases [65] including de- ly stage of development. He believed that alex-
pression [66], anxiety disorders [67], eating dis- ithymic people are the people who experienced
orders [68], hypertension [69], diabetes [70] and trauma in early childhood. Consequently, in the
psoriasis [71] have been reported. Alexithymic face of overwhelming fear, it leads to the phe-
features are relatively common in the general nomenon of regression, resulting in secondary
population, occurring in 10% of adults, slight- somatization (resomatization) of mental process-
ly more frequently in men [72]. There are many es. People who have experienced long-term trau-
concepts of its development. Genetic, neurobio- ma in childhood, could fail in desomatization.
logical and environmental factors are considered As a result, the presentation of mental states is
to be essential. Referring to the etiology, Hell- not transferred from the body into the realm of
muth Freiberger [73] introduced a distinction be- mind [2]. Currently, it seems reasonable to ask
Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76
72 Anna Ostachowska et al.

about the diagnosis and treatment of difficulties or ventral precuneus, posterior cingulate gyrus
associated with recognizing one’s own emotion- and anterior medial thalamus, and that the auto-
al states in terms of prevention or potentiation of nomic nervous system affects the occurrence and
treatment of somatic diseases. severity of symptom in the body. At the same
time the researchers pay attention to the fact that
their findings are consistent with the theory, ac-
Functional imaging cording to which somatization is associated with
cognitive style characterized by affective content
The literature extensively describes changes rumination [85].
in the nervous system of patients with mental
disorders, including psychosomatic symptoms.
The observation of these changes is possible by Diagnostics and treatment
functional imaging techniques, such as func-
tional nuclear magnetic resonance (fMRI), sin- In addition to the broad diagnostic capabili-
gle photon emission tomography (SPECT), mag- ties, functional examination enables an assess-
netoencephalography (MEG) and positron emis- ment of the impact of pharmacological and psy-
sion tomography (PET). As an example, there is chotherapeutic treatment on nervous system me-
a study in which the neurophysiological basis of tabolism modification, which in recent years has
alexithymia, indicating a malfunction of anterior been repeatedly demonstrated [86]. It must be
cingulate gyrus has been evaluated [79-81]. Has- remembered that modern methods of brain im-
se Karlsson et al., have found that the reduced aging, although they are a milestone for the de-
activation of the anterior cingulate gyrus is also velopment of medical knowledge and make it
correlated with the increase in the activation possible to objectify the diagnosis and assess-
of the motor and somatosensory cortex, which ment of treatment effects, are burdened with the
could explain the mechanism of occurrence of necessity of scientific reductionism in describing
somatic symptoms with the lack of recognition mental processes [87].
of experienced emotions. Julian F. Thayer et al. The clinical management still lacks clear
created a neurophysiological model of emotion guidelines for psychological and psychiatric di-
regulation on the basis of functional examination agnosis in patients with symptoms which sug-
[82]. According to him, during emotional stress gest somatization. Due to the high comorbidity
increases the activity of the limbic system and of somatic diseases with mental disorders, the
certain prefrontal areas and there is a general de- implementation of diagnostic screening for men-
crease in activity of the prefrontal cortex, which tal health disorders, appears to be indispensa-
triggers the automatic system of behavior con- ble at some stage. Moreover, the conclusions of
trol [83]. This concept corresponds with mod- a meta-analysis of several studies clearly confirm
el of cognitive-emotional impulse control pro- that, in the treatment of somatoform disorders,
posed by Sylvie J M van der Kruijs [84]. Explain- psychotherapy is more effective than standard
ing the phenomenon of dissociation, the model method (d=0.80 vs. d=0.31, p <0.05) [87]. Control
assumes that in the optimal emotional state the studies show that the positive effect of the treat-
motor areas of the brain to a small extent are af- ment occurs in case of psychotherapy and physi-
fected by emotions. However, in case of inten- cal exercises, but it has not been observed for the
sive emotional arousal, the centre responsible for administration of medicines [88-91]. Changes in
the cognitive processing of excitation is omitted. DSM-5 come in the aid of diagnosticians, free-
In the imaging examination, the described mod- ing them from the necessity to exclude organic
el appears to be an increase in functional con- cause in the case of unexplained somatic symp-
nection of the motor cortex with the limbic sys- toms. Such an approach is also close to the psy-
tem with reduced prefrontal cortex impulsation. choanalytic perspective. In psychotherapy, pa-
In another report, the researchers suggest that tients with somatic symptoms of mental disor-
the phenomenon of somatization measured us- ders, the prospect of an organic explanation of
ing a self-assessment questionnaire (SOMS-2) is complaints by the appropriate expert inhibits the
associated with increased activity in the anteri- progress of therapy.
Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76
 Symptoms of cardiovascular diseases in the course of mental disorders 73

The treatment of these diseases emphasizes 3. Rodin GM. Somatization: a Perspective from Self Psycholo-
the importance of awareness, disclosure and ex- gy. J Am Acad Psychoanal. 1991; 19(3): 367–384.
periencing emotions, which is the core of psy- 4. Rask MT, Andersen RS, Bro F, Fink P, Rosendal M. Towards
chodynamic psychotherapy [92]. In studies in a clinically useful diagnosis for mild – to-moderate condi-
the general population it has been shown that tions of medically unexplained symptoms in general practice:
training in naming emotions and reading liter- a mixed methods study. BMC Family Practice. 2014; 15: 118.
ary fiction [93] is beneficial for identifying one’s 5. American Psychiatric Association, American Psychiatric As-
own emotional states and affective regulation sociation, editors. Diagnostic and statistical manual of mental
[94]. Psychotherapy also reduces the symptoms disorders: DSM-5. 5th ed. Washington, D.C: American Psy-
of alexithymia, although there is still a need to chiatric Association; 2013. p. 947.
develop an individualized procedure in this re- 6. Sirri L, Fava GA. Diagnostic criteria for psychosomatic re-
spect [95]. In examining the impact of pharma- search and somatic symptom disorders. International Re-
cology, Anthony Lane et al. (2013) showed that view of Psychiatry. 2013; 25(1): 19-30.
oxytocin administered intranasally increase peo- 7. Coulshed DS, Eslick GD, Talley NJ. Non-cardiac chest pain.
ple’s will to share their painful emotions [96]. Patients need diagnoses. BMJ. 2002; 324(7342): 915.
Another therapeutic option is transcranial mag- 8. Fass R, Achem SR. Noncardiac chest pain: epidemiology,
netic stimulation of the brain areas responsible natural course and pathogenesis. J Neurogastroenterol Mo-
for experiencing emotions and linguistic prop- til. 2011; 17(2): 110–23.
erties [97, 98]. Further studies in this regard, as- 9. Eken C, Oktay C, Bacanli A, Gulen B, Koparan C, Ugras SS,
sessing various therapeutic interventions in ran- et al. Anxiety and depressive disorders in patients present-
domized trials are needed. ing with chest pain to the emergency department: a compar-
ison between cardiac and non-cardiac origin. J Emerg Med.
2010; 39(2): 144–150.
Recapitulation 10. Rohani A, Akbari V, Zarei F. Anxiety and depression symp-
toms in chest pain patients referred for the exercise stress test.
In medical practice we often meet patients Heart Views Off J Gulf Heart Assoc. 2011; 12(4): 161–164.
with somatic symptoms without organic cause. 11. Robertson N, Javed N, Samani NJ, Khunti K. Psychologi-
In this case, usually reported symptoms are ac- cal morbidity and illness appraisals of patients with cardiac
companied by undiagnosed mental health prob- and non-cardiac chest pain attending a rapid access chest
lems, which are often a significant factor in the pain clinic: a longitudinal cohort study. Heart Br Card Soc.
risk of serious somatic illness. Despite the lack of 2008; 94(3): e12.
a diagnosed organic cause, these symptoms are 12. Coulshed DS, Eslick GD, Talley NJ. Non-cardiac chest pain.
a cause of disability and withdrawal from nor- Patients need diagnoses. BMJ. 2002; 324(7342): 915.
mal social life. In addition, deepening and re- 13. Liu L, Cohen S, Schulz MS, Waldinger RJ. Sources of so-
peating diagnostic test for unexplained somat- matization: exploring the roles of insecurity in relationships
ic symptoms increases patient’s anxiety, which and styles of anger experience and expression. Soc Sci Med
exacerbate symptoms, and generates considera- 1982. 2011; 73(9): 1436–1443.
ble cost to the health care system. Unfortunate- 14. Sobański J, Klasa K, Popiołek L, Rutkowski K, Dembińska E,
ly, there is still a lack of clear guidelines for di- Mielimąka M, Cyranka K, Müldner – Nieckowski Ł, Smiatek-
agnosis and treatment of psychosomatic disor- Mazgaj B, Rodziński P. Complaints of patients suffering from
ders in primary care, and in many departments neurotic disorders, interesting for cardiologist. Kardiologia Pol-
involved in the treatment of somatic illnesses. ska. 2015; doi: 10.5603/KP.a2015.0099 [Epub ahead of print]
15. Eslick GD, Talley NJ. Natural history and predictors of out-
REFERENCES come for non-cardiac chest pain: a prospective 4-year cohort
study. Neurogastroenterol Motil Off J Eur Gastrointest Motil
1. Sobczak M, Kasprzak JD, Drygas In. Psychocardiology – Soc. 2008; 20(9): 989–97.
introduction to a new scientific discipline. Kardiol Pol. 2011; 16. Bass C, Mayou R. Chest pain. BMJ. 2002; 325(7364): 588–
69(8): 838–843. 591.
2. Schier K. Bez tchu i bez słowa: więź psychiczna i regulac- 17. McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM.
ja emocji u osób chorych na astmę oskrzelową. Gdańsk: Opening Pandora’s box: the unpredictability of reassurance
Gdańskie Wydawnictwo Psychologiczne; 2005. by a normal test result. BMJ. 1996 ; 313(7053): 329–332.

Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76

74 Anna Ostachowska et al.

18. Nijher G, Weinman J, Bass C, Chambers J. Chest pain 31. Levenson JL. The somatoform disorders: 6 characters in
in people with normal coronary anatomy. BMJ. 2001; search of an author. Psychiatr Clin North Am. 2011; 34(3):
323(7325): 1319–1320. 515–524.
19. Hadlandsmyth K, Rosenbaum DL, Craft JM, Gervino EV, 32. Murray AM, Toussaint A, Althaus A, Löwe B. Barriers to the
White KS. Health care utilisation in patients with non-car- diagnosis of somatoform disorders in primary care: proto-
diac chest pain: a longitudinal analysis of chest pain, anx- col for a systematic review of the current status. Syst Rev.
iety and interoceptive fear. Psychol Health. 2013; 28(8): 2013; 2: 99.
849–861. 33. Smith RC, Dwamena FC. Classification and diagnosis of pa-
20. Kisely S, Goldberg D, Simon G. A comparison between so- tients with medically unexplained symptoms. J Gen Intern
matic symptoms with and without clear organic cause: re- Med. 2007; 22(5): 685–691.
sults of an international study. Psychol Med. 1997; 27(5): 34. Schaefert R, Hausteiner-Wiehle C, Häuser W, Ronel J, Her-
1011–1019.
rmann M, Henningsen P. Non – specific, functional, and so-
21. Bermingham SL, Cohen A, Hague J, Parsonage M. The cost matoform bodily complaints. Dtsch Ärztebl Int. 2012; 109(47):
of somatisation among the working‐ age population in Eng- 803–813.
land for the year 2008–2009. Mental Health in Family Medi-
35. Soares-Filho GLF, Mesquita CT, Mesquita ET, Arias-Carrión
cine. 2010; 7(2): 71-84.
O, Machado S, González MM, et al. Panic attack triggering
22. Röhricht F, Elanjithara T. Management of medically unex- myocardial ischemia documented by myocardial perfusion
plained symptoms: outcomes of a specialist liaison clinic. imaging study. A case report. Int Arch Med. 2012; 5(1): 24.
Psychiatr Bull 2014. 2014;38(3): 102–107.
36. Huffman JC, Pollack MH, Stern TA. Panic Disorder and
23. National Collaborating Centre for Mental Health (UK). De- Chest Pain: Mechanisms, Morbidity, and Management. Prim
pression: The Treatment and Management of Depression Care Companion J Clin Psychiatry. 2002;4(2):54–62.
in Adults (Updated Edition) [Internet]. Leicester (UK): Brit-
37. Fujii H, Yasue H, Okumura K, Matsuyama K, Morikami Y, Mi-
ish Psychological Society; 2010 [cited 2015 May 8]. Avail-
yagi H, et al. Hyperventilation – induced simultaneous mul-
able from: http://www.ncbi.nlm.nih.gov/books/ NBK63748/
tivessel coronary spasm in patients with variant angina: an
24. Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An echocardiographic and arteriographic study. J Am Coll Car-
international study of the relation between somatic symptoms diol. 1988; 12(5): 1184–92.
and depression. N Engl J Med. 1999; 341(18): 1329–1335.
38. Beitman BD, Basha I, Flaker G, Derosear L, Mukerji V, Lam-
25. Agüera L, Failde I, Cervilla JA, Díaz-Fernández P, Mico JA. berti J. Non-fearful panic disorder: Panic attacks without fear.
Medically unexplained pain complaints are associated with
Behav Res Ther. 1987; 25(6): 487–492.
underlying unrecognized mood disorders in primary care.
BMC Fam Pract. 2010; 11: 17. 39. Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg
J, Longe TF, et al. Acute and reversible cardiomyopathy pro-
26. National Clinical Guideline Centre for Acute and Chronic
voked by stress in women from the United States. Circula-
Conditions (UK). Chest Pain of Recent Onset: Assessment
tion. 2005; 111(4): 472–479.
and Diagnosis of Recent Onset Chest Pain or Discomfort of
Suspected Cardiac Origin [Internet]. London: Royal College 40. Amruthlal Jain SK, Larsen TR, Souqiyyeh A, David SW. Ta-
of Physicians (UK); 2010 [cited 2015 May 5]. Available from: kotsubo cardiomyopathy: reversible stress-induced cardi-
http://www.ncbi.nlm.nih.gov/books/NBK63790/ ac insult-a stress protective mechanism. Am J Cardiovasc
Dis.2013;3(1):53–59.
27. Webster R, Norman P, Goodacre S, Thompson AR,
McEachan RRC. Illness representations, psychological dis- 41. Deshmukh A, Kumar G, Pant S, Rihal C, Murugiah K, Mehta
tress and non-cardiac chest pain in patients attending an JL. Prevalence of Takotsubo cardiomyopathy in the United
emergency department. Psychol Health. 2014;29(11): 1265– States. Am Heart J. 2012;164(1):66–71.
1282. 42. El-Sayed AM, Brinjikji W, Salka S. Demographic and co-mor-
28. Ladwig K-H, Lederbogen F, Albus C, Angermann C, Borg- bid predictors of stress (takotsubo) cardiomyopathy. Am J
grefe M, Fischer D, et al. Position paper on the importance Cardiol. 2012; 110(9): 1368–1372.
of psychosocial factors in cardiology: Update 2013. Ger Med 43. Iga K, Gen H, Tomonaga G, Matsumura T, Hori K. Revers-
Sci GMS E – J. 2014;12:Doc09. ible left ventricular wall motion impairment caused by phe-
29. Harris AM, Orav EJ, Bates DW, Barsky AJ. Somatization in- ochromocytoma--a case report. Jpn Circ J. 1989; 53(7):
creases disability independent of comorbidity. J Gen Intern 813–818.
Med. 2009; 24(2): 155–161. 44. Nef HM, Möllmann H, Troidl C, Kostin S, Voss S, Hilpert P,
30. Hocaoglu C, Gulec MY, Durmus I. Psychiatric comorbidity in et al. Abnormalities in intracellular Ca2+ regulation contrib-
patients with chest pain without a cardiac etiology. Isr J Psy- ute to the pathomechanism of Tako-Tsubo cardiomyopathy.
chiatry Relat Sci. 2008; 45(1): 49–54. Eur Heart J. 2009; 30(17): 2155–2164.

Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76

 Symptoms of cardiovascular diseases in the course of mental disorders 75

45. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn 59. Aleksandrowicz J. Zaburzenia nerwicowe. Warszawa:
E. Apical ballooning syndrome or takotsubo cardiomyopa- Wydawnictwo Lekarskie PZWL; 1998.
thy: a systematic review. Eur Heart J. 2006; 27(13): 1523– 60. Taylor GJ, Bagby RM, Parker JDA. Disorders of affect reg-
1529. ulation: alexithymia in medical and psychiatric illness. Cam-
46. Flesher MR, Delahanty DL, Raimonde AJ, Spoonster E. Am- bridge: Cambridge University Press; 1999. 359 p.
nesia, neuroendocrine levels and PTSD in motor vehicle ac- 61. Freud S, Freud A, Bonaparte M. Werke aus den Jahren
cident victims. Brain Inj. 2001; 15(10): 879–89. 1892-1899. 6. Aufl. Frankfurt: Fischer; 1991. 594 p.
47. Pantoni L, Lamassa M, Inzitari D. Transient global amne- 62. Koh KB, Park JK. The relation between anger management
sia: a review emphasizing pathogenic aspects. Acta Neurol style and organ system-related somatic symptoms in patients
Scand. 2000; 102(5): 275–283. with depressive disorders and somatoform disorders. Yonsei
48. Toussi A, Bryk J, Alam A. Forgetting heart break: a fascinat- Med J. 2008;49(1): 46–52.
ing case of transient left ventricular apical ballooning syn- 63. Denollet J, Schiffer AA, Spek V. A general propensity to psy-
drome associated with dissociative amnesia. Gen Hosp Psy- chological distress affects cardiovascular outcomes: evi-
chiatry. 2014; 36(2): 225–227. dence from research on the type D (distressed) personality
49. Wittstein IS, Thiemann DR, Lima JAC, Baughman KL, Schul- profile. Circ Cardiovasc Qual Outcomes. 2010; 3(5): 546–57.
man SP, Gerstenblith G, et al. Neurohumoral features of my- 64. Sifneos PE. The prevalence of “alexithymic” characteristics
ocardial stunning due to sudden emotional stress. N Engl J in psychosomatic patients. Psychother Psychosom. 1973;
Med. 2005; 352(6): 539–548. 22(2): 255–262.
50. Alberici E, Pichiecchio A, Caverzasi E, Farina LM, Persico 65. Karukivi M, Saarijärvi S. Development of alexithymic person-
A, Cavallini A, et al. Transient global amnesia: hippocampal ality features. World J Psychiatry. 2014; 4(4): 91–102.
magnetic resonance imaging abnormalities. Funct Neurol. 66. Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Vii-
2008; 23(3): 149– 152. namäki H. Depression is strongly associated with alexithy-
51. Heszen-Niejodek I, Sęk H. Psychologia zdrowia. Warszawa: mia in the general population. J Psychosom Res. 2000;
Wydawnictwo Naukowe PWN; 2007. 48(1): 99–104.
52. Linden W, Phillips MJ, Leclerc J. Psychological treatment of 67. Marchesi C, Fontò S, Balista C, Cimmino C, Maggini C. Re-
cardiac patients: a meta-analysis. Eur Heart J. 2007; 28(24): lationship between alexithymia and panic disorder: a longi-
2972–2984. tudinal study to answer an open question. Psychother Psy-
53. Charlson FJ, Moran AE, Freedman G, Norman RE, Stapel- chosom. 2005; 74(1): 56–60.
berg NJC, Baxter AJ, et al. The contribution of major depres- 68. Taylor GJ, Parker JD, Bagby RM, Bourke MP. Relation-
sion to the global burden of ischemic heart disease: a com- ships between alexithymia and psychological characteris-
parative risk assessment. BMC Med. 2013; 11: 250. tics associated with eating disorders. J Psychosom Res.
54. Meng L, Chen D, Yang Y, Zheng Y, Hui R. Depression in- 1996;41(6):561– 8.
creases the risk of hypertension incidence: a meta-analy- 69. Grabe HJ, Schwahn C, Barnow S, Spitzer C, John U, Frey-
sis of prospective cohort studies. J Hypertens. 2012; 30(5): berger HJ, et al. Alexithymia, hypertension, and subclinical
842–851. atherosclerosis in the general population. J Psychosom Res.
55. Hildrum B, Mykletun A, Holmen J, Dahl AA. Effect of anxi- 2010; 68(2): 139–147.
ety and depression on blood pressure: 11-year longitudinal 70. Chatzi L, Bitsios P, Solidaki E, Christou I, Kyrlaki E, Sfakiana-
population study. Br J Psychiatry J Ment Sci. 2008; 193(2): ki M, et al. Type 1 diabetes is associated with alexithymia in
108–113. nondepressed, non-mentally ill diabetic patients: a case-con-
56. Hildrum B, Romild U, Holmen J. Anxiety and depression low- trol study. J Psychosom Res. 2009; 67(4): 307–313.
ers blood pressure: 22-year follow – up of the population based 71. Picardi A, Mazzotti E, Gaetano P, Cattaruzza MS, Baliva G,
HUNT study, Norway. BMC Public Health. 2011; 11: 601. Melchi CF, et al. Stress, social support, emotional regulation,
57. Lambert E, Dawood T, Straznicky N, Sari C, Schlaich M, and exacerbation of diffuse plaque psoriasis. Psychosomat-
Esler M, et al. Association between the sympathetic firing ics. 2005; 46(6): 556–64.
pattern and anxiety level in patients with the metabolic syn- 72. Salminen JK, Saarijärvi S, Aärelä E, Toikka T, Kauhanen J.
drome and elevated blood pressure. J Hypertens. 2010; Prevalence of alexithymia and its association with sociode-
28(3): 543–50. mographic variables in the general population of Finland. J
58. Aleksandrowicz JW. Zaburzenia nerwicowe, zaburzenia Psychosom Res. 1999; 46(1): 75–82.
osobowości i zachowania dorosłych (według ICD-10): psy- 73. Freyberger H. Supportive psychotherapeutic techniques in
chopatologia, diagnostyka, leczenie. Kraków: Wydawnictwo primary and secondary alexithymia. Psychother Psychosom.
Uniwersytetu Jagiellońskiego; 1998. 1977; 28(1-4): 337–342.

Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76

76 Anna Ostachowska et al.

74. Krystal H. Alexithymia and the effectiveness of psychoana- ness of psychotherapy for severe somatoform disorder: me-
lytic treatment. Int J Psychoanal Psychother. 1982/1983;9: ta-analysis. Br J Psychiatry. 2014; 204(1): 12–9.
353–378. 87. Walter H, Berger M, Schnell K. Neuropsychotherapy: con-
75. Zeitlin SB, McNally RJ, Cassiday KL. Alexithymia in victims ceptual, empirical and neuroethical issues. Eur Arch Psychi-
of sexual assault: an effect of repeated traumatization? Am atry Clin Neurosci. 2009;259 Suppl 2:S173–82.
J Psychiatry. 1993; 150(4):661–663.
88. Daley AJ, Grimmett C, Roberts L, Wilson S, Fatek M, Roalfe
76. Orzechowska A, Denys K, Wachowska K, Zboralski K, Ta- A, et al. The effects of exercise upon symptoms and quality of
larowska M, Gałecki P. Alexithymia in patients with cardiac life in patients diagnosed with irritable bowel syndrome: a ran-
diseases and patients with mood disorders – preliminary re- domised controlled trial. Int J Sports Med. 2008; 29(9): 778–782.
ports. 2012; 13(1): 7–11.
89. Johannesson E, Simrén M, Strid H, Bajor A, Sadik R. Phys-
77. Stone LA, Nielson KA. Intact physiological response to
ical activity improves symptoms in irritable bowel syndrome:
arousal with impaired emotional recognition in alexithymia.
a randomized controlled trial. Am J Gastroenterol. 2011;
Psychother Psychosom. 2001 Apr;70(2): 92–102.
106(5): 915–922.
78. Brosschot JF, Aarsse HR. Restricted emotional processing
and somatic attribution in fibromyalgia. Int J Psychiatry Med. 90. Ford AC, Talley NJ, Schoenfeld PS, Quigley EMM, Moayyedi
2001; 31(2): 127–146. P. Efficacy of antidepressants and psychological therapies in
irritable bowel syndrome: systematic review and meta-analy-
79. Kano M, Fukudo S, Gyoba J, Kamachi M, Tagawa M, Mochi-
sis. Gut. 2009; 58(3): 367–378.
zuki H, et al. Specific brain processing of facial expressions
in people with alexithymia: an H2 15O-PET study. Brain J 91. Eich W, Häuser W, Arnold B, Bernardy K, Brückle W, Ei-
Neurol. 2003; 126(6): 1474–1484. dmann U, et al. Das Fibromyalgiesyndrom: Allgemeine Be-
80. Lane RD, Ahern GL, Schwartz GE, Kaszniak AW. Is alexithy- handlungsgrundsätze, Versorgungskoordination und Patien-
mia the emotional equivalent of blindsight? Biol Psychiatry. tenschulung. Schmerz. 2012; 26(3): 268–275.
1997; 42(9): 834–44. 92. Kaplan MJ. A Psychodynamic Perspective on Treatment of
81. Karlsson H, Näätänen P, Stenman H. Cortical activation in Patients with Conversion and Other Somatoform Disorders.
alexithymia as a response to emotional stimuli. Br J Psychi- Psychodyn Psychiatry. 2014; 42(4): 593–615.
atry J Ment Sci. 2008; 192(1):32–38. 93. Kidd DC, Castano E. Reading literary fiction improves theory
82. Thayer JF, Hansen AL, Saus-Rose E, Johnsen BH. Heart of mind. Science. 2013; 342 (6156): 377–380.
rate variability, prefrontal neural function, and cognitive per- 94. Lieberman MD, Inagaki TK, Tabibnia G, Crockett MJ. Subjec-
formance: the neurovisceral integration perspective on self- tive responses to emotional stimuli during labeling, reapprais-
regulation, adaptation, and health. Ann Behav Med Publ Soc al, and distraction. Emot Wash DC. 2011; 11(3): 468–480.
Behav Med. 2009; 37(2): 141–153.
95. Samur D, Tops M, Schlinkert C, Quirin M, Cuijpers P, Koole
83. Van der Kruijs SJM, Bodde NMG, Carrette E, Lazeron RHC,
SL. Four decades of research on alexithymia: moving toward
Vonck KEJ, Boon PAJM, et al. Neurophysiological correlates
clinical applications. Front Psychol. 2013; 4: 861.
of dissociative symptoms. J Neurol Neurosurg Psychiatry.
2014;85(2):174–179. 96. Lane A, Luminet O, Rimé B, Gross JJ, de Timary P, Mikolajc-
zak M. Oxytocin increases willingness to socially share one’s
84. Van der Kruijs SJM, Bodde NMG, Vaessen MJ, Lazeron
RHC, Vonck K, Boon P, et al. Functional connectivity of dis- emotions. Int J Psychol J Int Psychol. 2013; 48(4): 676–681.
sociation in patients with psychogenic non-epileptic seizures. 97. Hoekert M, Vingerhoets G, Aleman A. Results of a pilot study
J Neurol Neurosurg Psychiatry. 2012;83(3):239–247. on the involvement of bilateral inferior frontal gyri in emo-
85. Lemche E, Giampietro VP, Brammer MJ, Surguladze SA, tional prosody perception: an rTMS study. BMC Neurosci.
Williams SCR, Phillips ML. Somatization severity asso- 2010; 11: 93.
ciated with postero-medial complex structures. Sci Rep. 98. Bernhardt BC, Valk SL, Silani G, Bird G, Frith U, Singer T.
2013;3:1032. Selective disruption of sociocognitive structural brain net-
86. Koelen JA, Houtveen JH, Abbass A, Luyten P, Eurelings-Bon- works in autism and alexithymia. Cereb Cortex N Y N 1991.
tekoe EHM, Van Broeckhuysen – Kloth SAM, et al. Effective- 2014; 24(12): 3258– 3267.

Archives of Psychiatry and Psychotherapy, 2015; 4: 66–76