Social Cognition and Levels of Personality Organization in Patients With Somatoform Disorders A Case-Control Study Jurrijn A. Koelen, PhD,*Þ Elisabeth H.M. Eurelings-Bontekoe, PhD,þ Saskia A.M. van Broeckhuysen-Kloth, PhD,* Wim M. Snellen, MSc,§ and Patrick Luyten, PhDÞ|| Abstract: Social cognition and its association with level of personality organi- zation (PO) were examined in 163 patients with severe somatoform disorders (SFDs) and 151 psychiatric (PSA) control patients. Social cognition was mea- sured with the Social Cognition and Object Relations Scale, which assessed both affective and cognitive facets of social cognition. Levels of PO were as- sessed using theory-driven profiles of the Dutch Short Form of the Minnesota Multiphasic Personality Inventory (MMPI). The SFD patients exhibited im- pairments in the cognitive facets of social cognition but not more so than the PSA controls. The results for the affective aspects indicated that the SFD patients exhibited lower levels of emotional investment yet higher affect tone in interactions than the PSA controls. In contrast to the control group, level of PO was not associated with social cognition in SFD. Together, the results indicated that impairments in complexity of mental representations are not specific to SFD patients, yet impairments in emotional investment may be specific to SFD. Key Words: Somatoform disorders, social cognition, theory of mind, Social Cognition and Object Relations Scale, personality organization, level of personality functioning. (J Nerv Ment Dis 2014;202: 217Y223) S omatoform disorders (SFDs) are among the most prevalent and disabling psychiatric (PSA) disorders, with prevalence rates as high as 16% in general practice (De Waal et al., 2004) and up to 35% in outpatient care (Okasha et al., 1996). The primary diagnostic fea- ture of patients with SFD is the presentation of multiple physical symptoms for which there is no demonstrable pathophysiological pro- cess (American Psychiatric Association [APA], 2000, 2013). Second- ary features are the typical perceptual and cognitive distortions with regard to physical symptoms, that is, the tendency to be extremely preoccupied with symptoms or to attribute symptoms to a physical disease despite evidence to the contrary (Kirmayer and Looper, 2006; Rief and Broadbent, 2007). This often leads to a maladaptive pattern of illness behavior and help seeking (Chaturvedi et al., 2006) that is associated with complex and difficult treatment relationships (Hahn, 2001). Because social cognition underpins social behavior and shapes interpersonal relationships, there has been a renewed interest in social cognition in SFD patients in recent years (Leithner-Dziubas et al., 2010; Luyten and Van Houdenhove, 2013; Oldershaw et al., 2011; Subic-Wrana et al., 2010). Social cognition refers to a set of psycho- logical processes by which children and adults are able to understand both themselves and others in terms of internal mental states (Sharp et al., 2008). Hence, social cognition is a broad concept, and studies in this domain have focused on different aspects and dimensions of social cognition, ranging from studies focusing on basic affect rec- ognition to more complex tasks related to belief-desire reasoning and the inference of emotions and beliefs in others. These more complex abilities are often referred to as ‘‘theory of mind’’ (ToM). Complex social cognition typically involves the integration of cognition and affect, with affective features referring to the emotional content or affective quality of mental representations, whereas cognitive compo- nents refer to the cognitive content and the structural features or the level of differentiation and integration of mental representations of others (Eurelings-Bontekoe et al., 2009a; Hibbard et al., 1995). Three studies examined various aspects of social cognition, ranging in complexity, among patients with SFD and related disorders (Leithner-Dziubas et al., 2010; Oldershaw et al., 2011; Subic-Wrana et al., 2010). In a study by Oldershaw et al. (2011) among 45 patients with chronic fatigue syndrome, it was found that these patients, as compared with 50 healthy controls, showed impairments only on basic tasks involving emotion recognition but not on complex tasks in- volving social scenarios. However, another study among a sample of 30 hospitalized SFD patients showed that SFD patients, compared with healthy controls, showed severe deficits in social cognition that were not restricted to understanding of emotions but also involved deficits in more complex cognitive-emotional representations of others and inferential reasoning (Subic-Wrana et al., 2010). Similar findings were obtained in a pilot study among 22 patients with chronic pelvic pain (Leithner-Dziubas et al., 2010). This study showed that patients showed severe deficits in reflective functioning, a construct strongly affiliated with ToM. These results seem to suggest that patients with SFD and related disorders are impaired in complex social cognition skills, but results are contradictory, diagnostic groups are heteroge- neous, and the samples are rather small. The current study aimed to extend our understanding of social cognition among SFD patients by examining complex social cognition in a larger sample of patients with severe SFD. As noted, studies that examine social cognition may shed light on illness behavior and its impact on the therapeutic relationship. In addition, the renewed interest in social cognition may provide a better insight into the treatment of SFD patients because social cognition may be an important target for intervention (Luyten and Van Houdenhove, 2013; Rimes and Chalder, 2010). Personality Organization and Social Cognition In the present study, we also wanted to examine the associa- tion between personality organization (PO) and social cognition in SFD patients and PSA controls. The concept of PO refers to a set of relatively stable psychological features that dynamically organize mental processes and contents, such as mental representations of self and important others, into a coherent organization (Gamache et al., 2009). Levels of PO are typically assumed to be closely related to the ability to regulate stress and emotions in interpersonal situations and thus may impact social cognition as well (Caligor and Clarkin, 2010; ORIGINAL ARTICLE The Journal of Nervous and Mental Disease & Volume 202, Number 3, March 2014 www.jonmd.com 217 *Altrecht Psychosomatic Medicine Eikenboom, Zeist, the Netherlands; †Department of Psychology, University of Leuven, Leuven, Belgium; ‡Department of Clinical and Health Psychology, Leiden University, Leiden, the Netherlands; §Altrecht Center for Psychodiagnostic Assessment, Zeist, the Netherlands; and ||Research Department of Clinical, Educational and Health Psychology, University College London, London, UK. Send reprint requests to Jurrijn A. Koelen, PhD, Department of Psychology, University of Leuven, Leuven, Belgium. E-mail: jurkoel@gmail.com. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20203Y0217 DOI: 10.1097/NMD.0000000000000097 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.