International Journal of Applied Research and Studies (iJARS)

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

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Case Study
Attention, Verbal Learning and Memory deficits in Somatization
Disorder: A Pilot study

Authors:
1 2
Ansha Patel*, Korsi Dorene Kharshiing

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

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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;

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International Journal of Applied Research and Studies (iJARS)
ISSN: 2278-9480 Volume 3, Issue 6 (June - 2014)
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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.

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International Journal of Applied Research and Studies (iJARS)
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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.

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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

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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

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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.

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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. Study Significance Deficit/

Dimensions of Mean Standard t-
Groups Level Percentile non-deficit
Attention Deviation value
1. Normals 33.8 4.3 97th -100th No

0.16 NS
Part 1
Focused Patients 45.6 6.2 78th -84th No
Attention

(total time
Normals 52.5 6.1 89th No
taken in
seconds) 2.3 *
Part2
Patients 87.4 56.4 65th -68th No

2. Normals 2.53 1.4 68th-84th No

Sustained 17.14 **
Attention
Patients 14.7 2.3 10th-16th Yes
(Total errors)

3. Normals 1.2 1.4 66th -72th No

Divided 10.6 **
Attention
Patient 11.4 3.3 Below 3rd Yes
(Total errors)

*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

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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 65th -68th on the focused attention task part 1, in comparison to normal subjects group who obtained a
percentile score of 89. As illustrated in Table 1 shown above, the results of the present study suggests that
the study groups differed on the total time taken to complete focused attention task: Part 2 of the test (the t-
value was found to be 2.3).Additionally, the data obtained on this measure shows that the patients of
Somatization Disorder differed with the normal subjects on the basis of the obtained means (the mean of
normal subjects group for part 2 was 52.5 and that of patient group was 87.4). The result were not suggestive
of any deficits in any of the study groups, as the patients of Somatization Disorder obtained a percentile
score of 78th -84th on the focused attention task part-2, in comparison to normal subjects group who obtained
a percentile score of 97th -100th .

Results of Sustained Attention: The dimension of sustained attention refers to the capacity to attend to a task
in hand for a required period of time. Table 1 given above summarizes the results of the study groups on this
measure. On the basis of Table 1 shown above, it can be suggested that, the groups differed on the total error
score obtained on the measure of sustained attention (the t-value was found to be 17.1). The data obtained on
this measure also urges that the patients of Somatization Disorder differed with the normal subjects, on the
obtained means (mean of normal subjects group was 2.53 and that of patient group was 14.7) Additionally,
the results are indicative of sustained attention deficits in the Somatization group, as it was observed that the
patients of Somatization Disorder performed poorly on the task, making more errors, with a percentile score
of 10th- 16th in comparison to the normal subjects who had a percentile score of 68-84.

Results on Divided Attention Task: Divided attention refers to the ability to attend to two or more tasks
simultaneously. As per Table 1, given above, it can be seen that the results of the present study suggests that
the groups differed on the total errors on the divided attention task (the t value was found to be 10.6);
moreover patients of Somatization Disorder performed poorly on the task with deficits in performance and a
percentile score of below 3rd in comparison to the normal subjects who had a percentile score of 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

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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 Study Performance on Learning Trials

Learning Groups
Average words recalled on each trials Deficit/

Non deficit

12 33 2 3 4 5 Percentile scores Across the trials

10 11 11 12 12.5 85th -90th , No

Normals
60th -75th ,
25th -40th ,
30th ,20th -30th

Immediate Recall respectively

(no. of words Average words recalled on each trials Deficit/

recalled and relearnt) Non deficit

1 2 3 4 5 Percentile score Across the trials

7 8 8.5 9 9.5 40th-50th, Yes

Patients
5th-15th,

below 5th,

below 5th,

below 5th

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 -50th ,5 -15th,below

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5th,below 5th,and below 5th respectively. And the percentile score obtained by the normal subject group
from trials First to Fifth were 85th- 90th, 60th- 75th, 25th - 40th, 30th, and 25- 30th 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.

t
S Auditory Verbal Study Standard Significance Percentile Deficit/Non
Mean value
No. List Learning Groups Deviation Level score deficit

1. Total Learning Normals 51.3 2.0 25th-30th No

Score over 5 trials
(No. of words 4.0 **
recalled over 5
Patients 41.3 9.0 Below 5th Yes
trials)

2. Long Term Normals 107 5.2 85th No

Percentage
Retention Patients 81.6 31.7 2.9 ** 5-10th Yes
(Total no. of words)
3. Delayed Recall Normals 11 1.6 15th -20th No
(Total no. of words)
Patients 8 3.2 3 ** 5th Yes

4. Recognition Normals 14.3 0.26 15th -20th No

Hits
Patients 12 1.6 1.2 NS Below 5th 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 25th-30th and the patient group

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was less than 5th respectively which were suggestive of cognitive deficits in the patient group on the
subdomain of total learning.

The Long Term Percentage Retention on AVLT Task: Table 3 given above demonstrates the results on the
long term percentage retention task in which the subjects of the Somatization group differed significantly
from the normal subjects group (t-value came out to be 2.9). Another significant finding obtained on this
measure is that patients of Somatization Disorder differed with the normal subjects group on the basis of the
means obtained (mean of normal subjects group was 107 and that of the patient group was 81.6). The
percentile scores obtained by the normal subjects and the patient group were 85th and 5th-10th 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-20th and 5th 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 15th-20th and below 5th 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

Dimensions Standard
S No Study Mean Significance Percentile Deficit/
Of Deviation t-value
Groups level score non deficit
Logical Memory

Logical memory 15.6 2.4

Immediate recall Normals 50th -60th No
1. (total words 0.14 NS
recalled)
Patients 15.5 1.5 50th -60th No

Logical memory Normals 18.9 2.7 70th -75th No

Delayed recall
2. (total words 2.05
recalled) Patients 16.3 2.7 * 50th -60th 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 50th -60th in comparison to normal
subjects who also had an percentile score of 50th -60th 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-75th and 50th -

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60th respectively which were not suggestive of any cognitive deficits in Delayed Recall test of Logical
Memory.

In conclusion the review of results obtained in the present study indicate that significant cognitive deficits
were found in the Somatization patient group in comparison to normal controls on the subdomains of
attentional measures assessed namely, Sustained Attention, Divided Attention, and also on measures of
verbal learning and memory namely, Immediate Learning of a list of words, Total Learning a list of words,
Long Term Percentage Retention a list of words, Delayed Recall in list learning, and Recognition in List
Learning. No significant deficits were found on the subdomains of Focused Attention, Immediate Recall of
Logical Memory and Delayed Recall of Logical Memory.

Henceforth, as per the results of present research, the hypothesis 1 has thus been partially supported by the
findings in the present research. The hypotheses 2, 3,4,5,6 thus been supported by the findings in the present
research. And hypothesis 7, 8 has not been supported by the findings in the present research.

V. THE DISCUSSION

Clinical Neuropsychology combines the knowledge base developed through classical, neurology with the
modern methods of American psychometric psychology. Clinical neuropsychological assessment in
psychiatric disorders details with the behavioural expression of brain dysfunction and with the practical
problem of identification, assessment, psychosocial rehabilitation in patients with cognitive impairments.
Among the various psychiatric disorders, Somatoform Disorders, and more specifically Somatization
Disorder lies abundantly however inadequately explored with regard to its specific cognitive features and
neuropsychological manifestations which may indefinitely contribute to lower socio-occupational
functioning in them.

Considering the lacunas seen in the existing body of research, the aim of the present study was to assess the
patients of Somatization Disorder in comparison to normal subjects on basic cognitive functions like
Attention, Verbal Learning and Memory. The central premise that the present study explored is, whether
Somatization Disorder is associated with significant attention and learning and memory deficits that
represent as the basic lower level information processing units. The present study made one of the novel
attempts to identify etiological and remedial possibilities for any lower level cognitive problems of
Attention, Verbal Learning and Memory, using a deficit measurement paradigm of neuropsychological
assessment. Presented below are the domain wise results of the present investigation.

On the measures of attention: The Cognitive processing models have proposed that attentional processes
comprise of, vigilance, selection, dual-task performance and automaticity. More recently, several
components of attention like (a) deployment of attention, (b) capacity, (c) resistance to interference, and (d)
mental manipulation have been identified (Mapau, 1995). The findings of present study suggest that
although patients with Somatization Disorder perform adequately in tasks of Focused Attention, nevertheless
they seem to present with noteworthy cognitive deficits on the subdomains of attentional measures, namely

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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

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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),

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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

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Somatoform disorders, on larger samples, over longer time periods to ascertain nature, stability, pattern and
trajectories of cognitive functioning over time, in Somatoform Disorders.

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