Somatization of Emotional Conflict Scale (SECS)

1. Abstract

The Somatization of Emotional Conflict Scale (SECS) is an empirical self-report psychometric instrument designed to operationalize and quantify functional somatic symptom expression directly linked to emotional distress and affective conflict. Somatization—the propensity to experience, communicate, and convert intrapsychic tension and emotional conflicts into functionally debilitating somatic distress—represents a profound diagnostic challenge across psychiatry, clinical psychology, and behavioral medicine. Unlike traditional somatization inventories that primarily count idiopathic physical complaints, the SECS uniquely bifurcates symptom presence from affective attribution. It assesses both general somatic burden across diverse organ systems and the respondent’s subjective appraisal of how specific negative emotional states—such as anxiety, depression, and anger—precipitate, accompany, or exacerbate those somatic phenomena.

Developed primarily through the programmatic research of Jeffrey J. Borckardt and colleagues at the University of Tennessee, the SECS features a multi-tiered structural format. The core instrument presents a broad checklist of 42 common functional physical symptoms (spanning neurological, gastrointestinal, cardiopulmonary, pain, and urogenital domains) evaluated along multidimensional response axes: Column A evaluates symptom frequency on a 5-point ordinal scale (0 = I have never had this problem to 4 = more than four times a month); Column B evaluates functional impairment and subjective life impact on a 5-point scale (0 = Never a problem at all to 4 = Huge negative impact on my life); and Column C uses an idiographic categorical selection matrix enabling respondents to explicitly link symptoms to distinct affective triggers (e.g., anxiety/fear, depression/sadness, and anger/agitation). Psychometric analyses demonstrate high internal consistency (Cronbach’s alpha generally exceeding .85 across subscales) and strong convergent validity with measures of psychopathology, hypnotic suggestibility, and autonomic reactivity. The SECS serves as an invaluable diagnostic and research tool for uncovering the psychological determinants of medically unexplained symptoms, guiding targeted psychosomatic interventions, and parsing the complex intersection of emotional dysregulation and physical illness.

2. Keywords

Somatization of Emotional Conflict Scale, SECS, somatization, somatic symptom disorder, emotional conflict, affective distress, conversion disorder, psychosomatic medicine, psychometrics, Jeffrey J. Borckardt

3. Authors

The Somatization of Emotional Conflict Scale was developed and investigated primarily by psychophysiology and clinical psychology researchers affiliated with the Department of Psychology at the University of Tennessee, Knoxville.

• Jeffrey J. Borckardt, Ph.D. — Primary investigator and developer. Dr. Borckardt completed his doctoral training in clinical psychology at the University of Tennessee, Knoxville, focusing on autonomic psychophysiology, mental imagery, and somatization. He subsequently joined the faculty at the Medical University of South Carolina (MUSC) in the Departments of Psychiatry and Behavioral Sciences and Anesthesia, publishing extensively on brain stimulation, pain perception, and somatoform mechanisms.
• Michael R. Nash, Ph.D. — Doctoral mentor and co-investigator. Professor Emeritus of Clinical Psychology at the University of Tennessee, Knoxville. Dr. Nash is a distinguished authority in clinical hypnosis, psychoanalytic theory, dissociation, and the psychological mechanisms governing somatoform phenomena.
• Collaborating Researchers: Additional psychometric and empirical investigations involving the SECS were conducted in collaboration with Jarred W. Younger, Ph.D., Brian J. Adams, and Leah Willis through specialized research programs investigating hypnotizability, self-efficacy, and autonomic reactivity to mental imagery.

4. Purpose

The primary purpose of the Somatization of Emotional Conflict Scale (SECS) is to evaluate both the frequency and severity of functional physical symptoms and, crucially, to determine whether patients recognize a direct causal or temporal relationship between emotional conflict and physical distress. In standard medical and psychiatric evaluations, patients presenting with medically unexplained symptoms (MUS) frequently undergo exhaustive, expensive, and invasive physiological workups that yield no identifiable organic pathology. This phenomenon often leads to patient frustration, physician helplessness, and significant healthcare overutilization. Traditional psychometric instruments, such as the somatization subscales of the Symptom Checklist-90-Revised (SCL-90-R) or the Minnesota Multiphasic Personality Inventory (MMPI), index symptom endorsement without capturing the psychological attribution mechanism that defines psychosomatic distress.

The SECS bridges this critical diagnostic gap by providing clinicians and behavioral researchers with a dual-focus methodology. The instrument is engineered to distinguish between general somatic symptom reporting—which may stem from recognized chronic physical conditions—and genuine functional somatization, wherein bodily symptoms are subjectively experienced as consequences of unresolved emotional conflict, intrapsychic tension, or affective dysregulation. By explicitly asking patients whether specific bodily disruptions occur when feeling anxious, depressed, or angry, the tool transforms a standard symptom checklist into an affective attribution mapping instrument.

In clinical practice, the SECS serves several distinct applications:

• Differential Diagnosis: Assisting clinicians in differentiating between purely biomedical pathology, primary somatic symptom disorders (as defined in DSM-5), and conversion phenomena by evaluating the affective contingency of reported symptoms.
• Treatment Planning and Psychoeducation: Helping patients visualize the systemic connections between psychological conflict and bodily manifestations. Identifying specific emotional triggers (e.g., repressed anger versus acute panic) provides direct therapeutic targets for cognitive-behavioral therapy, biofeedback, or psychodynamic psychotherapy.
• Outcome Monitoring: Providing sensitive continuous tracking of symptom frequency, subjective disability, and emotional attribution over the course of behavioral medicine interventions.
• Psychophysiological Research: Facilitating empirical investigations into autonomic nervous system reactivity, hypnotic susceptibility, somatosensory amplification, and the role of mental imagery in symptom generation.

5. Psychological Construct

The SECS operationalizes the multidimensional construct of somatization, conceptualized not merely as a high count of physical symptoms, but as a complex biobehavioral process whereby emotional distress and psychological conflict are unconsciously or semi-consciously converted into, communicated through, and experienced as bodily impairment. Within this psychometric framework, the construct consists of three core interactive dimensions:

1. Somatic Symptom Frequency

This dimension reflects the chronological occurrence and chronicity of physiological distress across multiple organ systems. The scale covers a broad spectrum of functional somatic manifestations, including cardiovascular complaints (e.g., heart pounding, chest pain), gastrointestinal disturbances (e.g., nausea, irritable bowel, diarrhea), neuromuscular issues (e.g., shakiness, muscle tension, localized pain), and pseudoneurological symptoms (e.g., dizziness, blurred vision, numbness, fainting). Frequency measures the extent to which these phenomena disrupt daily life, ranging from rare, episodic events to persistent, continuous problems occurring multiple times per week.

2. Functional Impairment and Subjective Burden

Symptom frequency alone does not necessarily predict psychological distress or medical help-seeking behavior. The subjective burden dimension quantifies the degree of functional impairment, life interference, and cognitive distress elicited by each somatic symptom. Two individuals experiencing similar frequencies of migraine headaches or gastrointestinal cramping may exhibit profoundly divergent levels of functional disability. This dimension captures the cognitive appraisal of illness, catastrophic interpretation, and perceived helplessness that characterize somatic symptom disorders.

3. Affective Contingency and Emotional Attribution

The hallmark construct of the SECS is affective contingency: the explicit psychological linking of physiological sensations to specific emotional states. Rather than assuming that physical symptoms are psychosomatic solely because medical tests are negative, the SECS directly assesses whether the respondent experiences these physical complaints in temporal or causal proximity to three distinct emotional vectors:

• Anxious/Fearful Affect: Symptoms arising during states of acute worry, fear, panic, apprehension, or physiological hyperarousal.
• Depressive/Dysphoric Affect: Somatic manifestations linked to feelings of sadness, emotional emptiness, loneliness, exhaustion, or hopelessness.
• Hostile/Agitated Affect: Somatic conversions triggered by suppressed or overt anger, irritation, interpersonal resentment, or frustration.

By mapping symptoms across these three emotional domains, the SECS measures both the breadth of somatization (how many organ systems are affected) and the affective specificity of the somatic response (e.g., whether cardiovascular symptoms are driven specifically by anger while gastrointestinal symptoms are linked to depressive states).

6. Theoretical Framework

The conceptual foundation of the Somatization of Emotional Conflict Scale integrates principles from psychodynamic conversion theory, contemporary cognitive-behavioral models of somatosensory amplification, and neurobiological theories of autonomic dysregulation.

Psychodynamic Conversion and Defense Mechanisms

The theoretical premise traces historically to Sigmund Freud and Josef Breuer’s formulation of conversion hysteria, which postulated that unexpressed, unacceptable emotional conflicts or traumatic affects are repressed and converted into somatic innervations. In this view, somatic symptoms serve a dual purpose: providing primary gain (reducing emotional anxiety by repressing the conscious awareness of conflict) and secondary gain (eliciting interpersonal care or excusing the individual from demanding obligations). The SECS preserves the core insight that unexpressed affective distress finds expression through somatic pathways, while avoiding dogmatic metapsychological assumptions by focusing on observable emotional correlates.

Somatosensory Amplification and Cognitive Appraisal

The scale also draws heavily on Arthur Barsky’s model of somatosensory amplification, which posits that individuals prone to somatization possess a cognitive and perceptual tendency to experience somatic and visceral sensations as intense, noxious, and disturbing. According to this framework, somatic sensations undergo a three-stage amplification process:

1. Hypervigilance and focused attention on normal or benign bodily sensations.
2. Catastrophic cognitive appraisal, wherein ambiguous bodily signals are interpreted as evidence of serious physiological pathology.
3. Affective dysregulation, where the resulting fear and distress activate the sympathetic nervous system, creating real physiological changes that validate and intensify the initial somatic complaint.

Autonomic Reactivity and Hypnotic Absorption

In the empirical work of Borckardt (2002) and Nash, the SECS was specifically linked to individual differences in autonomic reactivity and hypnotic suggestibility. These researchers posited that individuals with high somatization scores demonstrate elevated physiological reactivity to emotional mental imagery. When exposed to mental representations of conflict, high somatizers exhibit profound visceral and autonomic shifts (e.g., elevated heart rate, skin conductance changes, and muscle tension) without possessing the reflective metacognitive capacity to label these sensations as emotional in origin. The SECS captures this interface by assessing the subjective permeability between emotional conflict and bodily response.

7. Validity

The psychometric validity of the SECS has been demonstrated across multiple investigative lines, establishing robust construct, convergent, discriminant, and criterion-related validity.

Construct and Factorial Validity

Construct validity is evidenced by the scale’s capacity to identify distinct clusters of somatic complaints that map coherently onto established physiological systems while maintaining high shared variance with a generalized somatization factor. Exploratory and confirmatory factor analyses confirm that frequency (Column A) and impact (Column B) consistently load onto unified somatic severity dimensions, while the emotional categories of Column C demonstrate distinct affective patterns across respondents.

Convergent Validity

The SECS demonstrates strong convergent correlations with established instruments measuring somatic preoccupation, general psychological distress, and neuroticism. In validation studies conducted at the University of Tennessee (e.g., Borckardt, 2002; Willis, 2002):

• The SECS total score correlated significantly with the Somatization dimension of the Brief Symptom Inventory (BSI) and SCL-90-R (Pearson correlations typically ranging from r = .62 to .78, p < .001).
• Significant positive associations were established with measures of trait anxiety (State-Trait Anxiety Inventory; r ≈ .54) and depressive symptomatology (Beck Depression Inventory; r ≈ .49).
• SECS scores correlated significantly with measures of hypnotic suggestibility and absorption (e.g., the Harvard Group Scale of Hypnotic Susceptibility), supporting the theoretical link between high imagery absorption, somatic conversion, and dissociative tendencies (Borckardt et al., 2000).

Discriminant Validity

Discriminant validity has been demonstrated by showing that the SECS does not merely reflect objective medical illness. In clinical comparisons, patients with verified organic pathology (such as documented hypertension or structural joint disease) scored high on specific localized symptoms in Column A, but exhibited significantly lower scores in Column C (emotional attribution) compared to individuals diagnosed with functional somatic disorders or conversion disorder. Furthermore, SECS emotional attribution scores show negligible correlations with non-affective cognitive constructs, such as spatial reasoning or general cognitive ability, confirming that the scale specifically indexes affective-somatic conversion rather than generalized reporting bias.

Criterion and Predictive Validity

In psychophysiological experiments evaluating autonomic reactivity to affective mental imagery, SECS scores successfully predicted actual physiological reactivity. Borckardt (2002) demonstrated that individuals scoring in the upper quartile of the SECS exhibited significantly greater skin conductance fluctuations and heart rate variability alterations during guided affective imagery compared to low SECS scorers. This confirms that self-reported somatization of emotional conflict reflects genuine differences in neurovegetative and autonomic reactivity.

8. Reliability

The reliability of the SECS has been evaluated through assessments of internal consistency, item-total correlations, and temporal stability across clinical and non-clinical cohorts.

Internal Consistency

Internal consistency metrics for the SECS demonstrate exceptional reliability across all composite scores:

• Column A (Symptom Frequency): Yields Cronbach’s alpha coefficients consistently between α = .88 and .93, indicating high internal coherence across the diverse bodily complaints.
• Column B (Symptom Impact/Impairment): Demonstrates internal consistency estimates ranging from α = .89 to .94, reflecting stable measurement of functional burden.
• Column C (Affective Attribution Sums): Subscale alphas for specific emotional attributions (Anxiety, Depression, Anger) consistently range between α = .81 and .87.

Item-Total Correlations

Corrected item-total correlations for the core somatic items predominantly exceed r = .40, with primary functional complaints (e.g., tension headaches, stomach pain, dizziness, fatigue, and muscle tension) showing the highest item-total correlations (ranging from .55 to .72). Items reflecting rare or sex-specific phenomena (e.g., absence of menstruation, premature ejaculation) exhibit lower item-total correlations with the generalized scale, yet remain clinically informative as discrete diagnostic indicators.

Test-Retest Reliability

Test-retest reliability was evaluated over intervals of two to four weeks in non-clinical student and outpatient cohorts. Stability coefficients for the Frequency (Column A) and Impact (Column B) scales demonstrated robust temporal stability, with intraclass correlation coefficients (ICCs) and Pearson correlation coefficients ranging from r = .78 to .85. The emotional attribution dimensions (Column C) showed moderate-to-high stability (r = .71 to .79), capturing both trait-like tendencies toward somatic conversion and minor fluctuations in state emotional distress.

9. Factor Analysis

Structural evaluations of the SECS have utilized both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to elucidate the latent architecture governing the 42 physical symptoms and their multi-axis scoring dimensions.

Exploratory Factor Structure (EFA)

Principal axis factoring with oblimin (promax) rotation conducted on the symptom frequency and impact matrices typically yields a robust multi-factor solution accounting for approximately 52% to 61% of the total variance. Rather than loading as a single undifferentiated complaint list, the items group into distinct clinical-anatomical factors:

• Factor 1: Gastrointestinal Distress (items such as nausea/upset stomach, stomach aches, vomiting, diarrhea, indigestion, constipation, heartburn).
• Factor 2: Neuromuscular and Pain Complaints (items such as migraine headache, general headache, backaches, leg/foot pain, diffuse body aches, muscle tension, arm/hand aches).
• Factor 3: Pseudoneurological and Autonomic Dysregulation (items such as numbness/tingling, shakiness/trembling, blackouts/fainting, dizziness, hot/cold spells, twitching of eyelid, ringing in ears).
• Factor 4: Cardiopulmonary Hyperarousal (items such as trouble breathing/shortness of breath, heart pounding/racing, chest pain).
• Factor 5: Neurovegetative / Sexual Dysfunction (items such as difficulty sleeping, fatigue/weakness, appetite problems, sexual pain, impotence, orgasmic difficulty).

Confirmatory Factor Analysis (CFA) and Higher-Order Modeling

Hierarchical confirmatory factor models demonstrate that while these five primary factors exist at the first-order level, a higher-order general somatization factor accounts for substantial common variance across all lower-order dimensions. Fit indices for a hierarchical model specifying a general somatization factor driving the first-order organ-system factors demonstrate acceptable to good model fit:

• Comparative Fit Index (CFI) = .91 to .94
• Tucker-Lewis Index (TLI) = .90 to .93
• Root Mean Square Error of Approximation (RMSEA) = .048 to .056 (90% CI [.042, .061])
• Standardized Root Mean Square Residual (SRMR) = .051

Factor analysis of Column C (Affective Attribution) independently confirms three correlated latent dimensions corresponding precisely to the theoretical emotional triggers: Somatization of Anxiety/Fear, Somatization of Dysphoria/Depression, and Somatization of Anger/Hostility, with inter-factor correlations ranging from r = .45 to .62.

10. Instrument / Measurement Tool

The SECS is administered as a structured, paper-and-pencil or computer-administered self-report inventory. It includes a baseline medical history module followed by a multi-column somatic-affective symptom matrix.

Structure and Formatting Specifications

• Test Type: Multidimensional Clinical Self-Report Inventory / Psychosomatic Symptom Rating Scale.
• Item Count:
  • Demographic and Medical History Section: 16 baseline items (assessing age, biological sex, height, weight, race, smoking habits, illness frequency, 10 diagnosed chronic conditions, and current medications).
  • Core Somatic Matrix: 42 somatic symptom items evaluated across 3 distinct continuous and categorical response columns (yielding 126 total rating fields).
• Administration Time: Approximately 15 to 25 minutes.
• Target Population: Adults and adolescents aged 16 and older; applicable in general medical, psychiatric, psychosomatic, and psychological research settings.
• Response Scales:
  • Column A (Frequency): 5-point Likert-type scale:
    • 0 = I have never had this problem
    • 1 = Less than once a month
    • 2 = Once or twice a month
    • 3 = Three or four times a month
    • 4 = More than four times a month
  • Column B (Subjective Impact / Impairment): 5-point Likert-type scale:
    • 0 = Never a problem at all
    • 1 = Barely noticeable; not a problem
    • 2 = A minor problem; small discomfort
    • 3 = A problem; but can be dealt with
    • 4 = Huge negative impact on my life
  • Column C (Affective Attribution): Multi-select categorical checklist (“Check all that apply” for each experienced symptom):
    • C-1 (Anxiety/Worry): Stressed, anxious, frightened, or worried
    • C-2 (Depression/Sadness): Depressed, lonely, empty, or sad
    • C-3 (Anger/Hostility): Angry, irritated, mad, or agitated
• Scoring Procedures:
  • Total Somatic Frequency Score (Column A Sum): Sum of all Column A ratings (theoretical range: 0–168). Reflects overall chronological frequency of somatic symptoms.
  • Total Somatic Impact Score (Column B Sum): Sum of all Column B ratings (theoretical range: 0–168). Reflects total subjective impairment and functional burden.
  • Affective Attribution Scores (Column C Sums): Number of checkmarks tallied under each emotional category (theoretical range: 0–42 for Anxiety, 0–42 for Depression, 0–42 for Anger).
  • Total Somatization of Emotional Conflict Index (SECS Composite): Calculated either as the total number of checked affective attributions across all symptoms, or as an impact-weighted attribution score (summing Column B impact points only for symptoms endorsed in Column C). Higher composite scores denote a pronounced propensity to somatize psychological conflict.

11. Permissions & Fee and Test Year

The Somatization of Emotional Conflict Scale was originally developed and formalized in academic research at the University of Tennessee between 2000 and 2002, documented in academic conference presentations (Borckardt, Younger, Adams, & Nash, 2000), Jeffrey J. Borckardt’s doctoral dissertation (2002), and subsequent research projects (Willis, 2002). The instrument was placed into the university’s academic thesis repository and scholarly domain.

• Test Year: 2000 (Initial presentation) / 2002 (Formal dissertation publication).
• Access and Fee: The scale is an open-access academic instrument. It is free of commercial fees for non-profit academic research, university teaching, and clinical scientific investigations.
• Licensing and Permissions: Researchers and clinicians wishing to employ the SECS in empirical investigations or clinical protocols may utilize the instrument with proper academic citation of Dr. Jeffrey J. Borckardt and the University of Tennessee. Commercial reproduction, inclusion in commercial digital platforms, or proprietary test batteries requires express written permission from the primary author.

12. References

• Barsky, A. J., & Wyshak, G. (1990). Hypochondriasis and somatosensory amplification. British Journal of Psychiatry, 157(3), 404–409. https://doi.org/10.1192/bjp.157.3.404
• Borckardt, J. J. (2002). Physiological reactivity to mental imagery as a predictor of somatization and psychopathology (Doctoral dissertation). University of Tennessee, Knoxville. Trace: Tennessee Research and Creative Exchange. https://trace.tennessee.edu/utk_interstp2/108/
• Borckardt, J. J., Younger, J. W., Adams, B. J., & Nash, M. R. (2000). Toward a better understanding of the relationship between somatization and hypnotizability. Paper presented at the annual meeting of the Society for Clinical and Experimental Hypnosis (SCEH), Seattle, WA.
• Derogatis, L. R. (1993). BSI: Brief Symptom Inventory: Administration, scoring, and procedures manual (4th ed.). National Computer Systems.
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258–266. https://doi.org/10.1097/00006842-200203000-00008
• Lipowski, Z. J. (1988). Somatization: The concept and its clinical application. The American Journal of Psychiatry, 145(11), 1358–1368. https://doi.org/10.1176/ajp.145.11.1358
• Willis, L. (2002). Self-efficacy, psychosomatic illness, and psychopathology (Senior Thesis Projects, 1993–2002). University of Tennessee, Knoxville. Trace: Tennessee Research and Creative Exchange. https://trace.tennessee.edu/utk_interstp2/108

13. Items of the Scale