Somatization of Emotional Conflict Scale (SECS)

1. Abstract

The Somatization of Emotional Conflict Scale (SECS), developed by Jeffrey J. Borckardt, Jarred W. Younger, B. J. Adams, and Michael R. Nash (2000; Borckardt, 2002), is a comprehensive multidimensional psychometric instrument designed to quantify the somatic manifestation of psychological distress and emotional conflict. Unlike traditional somatic symptom inventories that merely measure the presence or frequency of physical complaints—often confounding idiopathic or medically unexplained symptoms with documented physical pathology—the SECS uniquely evaluates three operational parameters for 42 distinct bodily symptoms: symptom frequency (Column A), perceived functional impact or life disruption (Column B), and explicit perceived attribution to distinct affective states (Column C: anxiety/stress, depression/sadness, and anger/agitation). In addition to the 42 core symptom items, the instrument includes an initial screening battery assessing medical diagnoses (e.g., irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, hypertension), current pharmacotherapy, general vulnerability to infectious illness, and demographic indicators. Psychometric evaluations across clinical, college, and community samples indicate robust internal consistency (Cronbach’s α typically ranging from .89 to .96 across total and subscale scores), strong convergent validity with established measures of bodily distress, somatosensory amplification, and psychological distress (such as the SCL-90-R Somatization subscale and the Beck Depression Inventory), and sound construct validity demonstrated through exploratory and confirmatory factor analyses. The SECS offers clinicians and researchers in psychosomatic medicine, behavioral medicine, health psychology, and clinical neuropsychology a granular, ecologically sensitive methodology to disentangle functional somatic syndromes, conversion phenomenology, and emotional distress amplification from purely organic pathophysiology.

2. Keywords

Somatization of Emotional Conflict Scale, SECS, somatization, functional somatic syndromes, somatosensory amplification, psychosomatic medicine, conversion disorder, affective dysregulation, bodily distress, hypochondriasis, psychometrics, mind-body interaction, autonomic arousal, emotional conflict.

3. Authors

The Somatization of Emotional Conflict Scale was conceived and standardized by a team of clinical and experimental psychologists at the University of Tennessee, Knoxville:

• Jeffrey J. Borckardt, Ph.D. — Department of Psychology, University of Tennessee, Knoxville; subsequently Professor at the Medical University of South Carolina (MUSC), Departments of Psychiatry and Behavioral Sciences, and Anesthesia and Perioperative Medicine. Dr. Borckardt has published extensively on pain perception, neuromodulation, brain stimulation, and the psychophysiology of somatic complaints.
• Jarred W. Younger, Ph.D. — Department of Psychology, University of Tennessee, Knoxville; currently Professor and Director of the Neuroinflammation, Pain, and Fatigue Laboratory at the University of Alabama at Birmingham (UAB), formerly at Stanford University School of Medicine. Dr. Younger specializes in neuroimmune mechanisms of chronic fatigue, fibromyalgia, and central pain processing.
• B. J. Adams, M.A. — Department of Psychology, University of Tennessee, Knoxville; researcher in clinical psychophysiology and psychological assessment.
• Michael R. Nash, Ph.D. — Professor Emeritus of Psychology, Department of Psychology, University of Tennessee, Knoxville. Dr. Nash is an internationally recognized authority on clinical hypnosis, psychoanalytic theory, dissociative phenomena, and the unconscious cognitive processes underlying somatoform and conversion symptoms.

4. Purpose

The primary clinical and research objective of the Somatization of Emotional Conflict Scale (SECS) is to provide an empirical, clinically nuanced evaluation of the degree to which an individual translates psychological friction, unexpressed emotional tension, and affective distress into subjective bodily symptomatology. Historically, the assessment of somatization within psychiatric nosology has been burdened by conceptual ambiguities. Standard instruments—such as the Somatization Index of the Symptom Checklist-90-Revised (SCL-90-R) or the Patient Health Questionnaire-15 (PHQ-15)—tabulate physical sensations without investigating the respondent’s subjective awareness of the emotional triggers driving those sensations. Consequently, patients with documented systemic medical diseases (e.g., systemic lupus erythematosus, multiple sclerosis, or rheumatoid arthritis) frequently obtain pathologically elevated scores on standard somatization inventories despite experiencing symptoms rooted entirely in organic tissue damage rather than psychological etiology.

The SECS resolves this psychometric confound by introducing a tripartite reporting matrix for each of 42 physical symptoms. Rather than assuming that a physical symptom is psychogenic solely because a diagnostic scan failed to reveal gross structural abnormalities, the SECS asks individuals to self-report:

1. The objective recurrence rate or temporal frequency of the somatic manifestation.
2. The functional burden or life disruption produced by the symptom.
3. The contingent affective context, explicitly probing whether the symptom emerges, escalates, or clusters around three core emotional states: (a) anxious/fearful arousal, (b) depressive/dysphoric helplessness, or (c) angry/irritable activation.

In behavioral medicine and psychosomatic specialty clinics, the SECS serves as an invaluable diagnostic and treatment-planning instrument. It helps clinicians systematically differentiate between primary organic pathologies, functional neurological disorders (conversion disorders), central sensitivity syndromes (such as irritable bowel syndrome and fibromyalgia), and alexithymia-mediated somatosensory amplification. In research contexts, the SECS provides an operational bridge between psychophysiological reactivity—such as autonomic nervous system hyper-responsiveness, elevated sympathetic tone, or hypnotizability—and subjective somatic reporting, elucidating how emotional conflict converts into visceral and musculoskeletal distress.

5. Psychological Construct

The psychological construct captured by the SECS is emotional conflict somatization—the tendency to experience, amplify, and express psychological distress, interpersonal conflict, or intrapsychic tension in the idiom of somatic illness. This overarching construct is subdivided into multiple interrelated empirical and behavioral dimensions:

1. Somatosensory Symptom Repertoire & Frequency

This dimension encompasses the range and temporal density of bodily sensations across multiple physiological organ systems. Somatization is rarely restricted to an isolated physiological channel; instead, individuals prone to somatization typically exhibit multisystemic involvement. The SECS evaluates symptoms spanning:

• Gastrointestinal functioning: Nausea, upset stomach, diarrhea, constipation, indigestion, stomach aches, vomiting, heartburn, and ulcers.
• Cardiorespiratory activity: Dyspnea (shortness of breath), tachycardia, chest pain, and hot or cold spells.
• Neurological and pseudoneurological sensations: Migraines, tension headaches, dizziness, blackouts, syncope, numbness, tingling, blurred vision, tinnitus, and eyelid twitching.
• Musculoskeletal complaints: Muscle tension, back pain, leg or foot pain, arm or hand aches, and diffuse bodily pain.
• Constitutional and vegetative features: Fatigue, weakness, sleep disturbances, appetite dysregulation, and paradoxical excessive energy bursts.
• Dermatological and immune-related manifestations: Skin rashes, acne, cold sores, and fever blisters.
• Urogenital and sexual difficulties: Dyspareunia, impotence, premature ejaculation, severe premenstrual syndrome (PMS), amenorrhea, and orgasmic dysfunction.

2. Subjective Impairment and Symptom Impact

The impact dimension assesses functional morbidity—the extent to which bodily complaints impede daily executive functioning, social participation, occupational performance, and overall quality of life. Research in health psychology demonstrates that symptom frequency and functional disability do not correlate linearly; high somatizers frequently experience catastrophic impairment even from low-frequency, mild sensations due to attentional hypervigilance, catastrophic cognitions, and illness-related behavior.

3. Affective Contingency and Emotional Attribution

This is the core conceptual innovation of the SECS. The construct does not treat somatization as a non-conscious blind spot alone, but measures the conscious or semi-conscious cognitive-emotional appraisal connecting bodily sensations with three distinct affective states:

• Anxiety/Fear Spectrum (Hyperarousal): Sensations arising when feeling stressed, anxious, frightened, or worried. This captures sympathetic autonomic activation, visceral hyperalgesia, and hyperventilation-driven symptoms (e.g., palpitations, tremors, dizziness, parasthesias).
• Depression/Dysphoria Spectrum (Hypoarousal & Exhaustion): Sensations emerging when feeling depressed, lonely, empty, or sad. This indexes psychomotor slowing, immune-inflammatory fatigue, chronic ache amplification, and neurovegetative decline.
• Anger/Hostility Spectrum (Suppressed Aggression): Sensations surfacing when feeling angry, irritated, mad, or agitated. This assesses somatic internalization of aggressive impulses, leading to arterial constriction, intense localized muscle tension, gastrointestinal hyperacidity, and vascular headaches.

6. Theoretical Framework

The SECS is grounded in the convergence of classical psychoanalytic theory, contemporary cognitive-behavioral paradigms of somatosensory amplification, and neurobiological models of autonomic dysregulation.

Psychoanalytic and Psychodynamic Roots

The conceptual foundation of somatization originates in the seminal observations of Sigmund Freud and Josef Breuer regarding conversion hysteria. In classic psychodynamic formulations, when an unacceptable emotional impulse, traumatic memory, or psychological conflict enters conscious awareness, it generates intense psychic anxiety. Through defense mechanisms—specifically repression and conversion—the psychological conflict is converted into an innocent physical dysfunction (the “primary gain” of symptom formation). This protects the individual from directly confronting the terrifying affect. Building upon these classical ideas, Franz Alexander and the Chicago Psychoanalytic Institute developed the field of psychosomatic medicine, identifying specific vegetative neuroses driven by unexpressed hostility, chronic dependency needs, or unresolved separation anxiety acting on autonomic neural circuits.

Cognitive-Behavioral and Somatosensory Amplification Models

Modern cognitive formulations, particularly Arthur Barsky’s model of somatosensory amplification (Barsky & Wyshak, 1990), posit that somatization results from a three-part cognitive-perceptual process:

1. Hypervigilant scanning and focused attention directed inward toward normal or benign physiological perturbations.
2. The cognitive tendency to appraise and catastrophize ambiguous, low-level visceral sensations as threatening, dangerous, or indicative of underlying physical breakdown.
3. An emotionally driven cascade of autonomic arousal that biochemically amplifies and reinforces the initial physiological sensation, confirming the patient’s fears in a self-reinforcing vicious cycle.

The Biopsychosocial and Neurovisceral Integration Perspectives

At the neurobiological level, the SECS aligns with Julian Thayer’s Neurovisceral Integration Model and Stephen Porges’ Polyvagal Theory. The central autonomic network (CAN)—incorporating the anterior cingulate cortex, insular cortex, amygdala, and prefrontal regions—dynamically orchestrates emotional regulation and autonomic, endocrine, and immune output. When emotional regulation fails or emotional conflict cannot be integrated cortically, parasympathetic vagal tone drops, leading to uninhibited sympathetic hyperarousal or maladaptive dorsal-vagal shutdown. This physiological dysregulation produces real, measurable somatic distress: vascular spasms, smooth muscle hypermotility, visceral hypersensitivity, and cytokine-mediated systemic inflammation. The SECS captures this interface by determining which specific emotional pathways evoke these downstream somatic expressions.

7. Validity

The psychometric validity of the SECS has been examined across several investigations evaluating its construct, convergent, discriminant, and predictive properties (Borckardt et al., 2000; Borckardt, 2002; Willis, 2002).

Convergent Validity

Convergent validity has been established by correlating SECS subscales and composite indices with gold-standard measures of somatic awareness, psychological distress, and neuroticism:

• SCL-90-R Somatization Dimension: Total frequency scores (Column A) and impact scores (Column B) on the SECS demonstrate strong positive correlations with the SCL-90-R Somatization subscale (typically r = .68 to .78, p < .001).
• Affective Measures: The SECS Column C Emotional Attribution scores demonstrate selective convergent associations with validated affective inventories. The Anxiety-attribution score correlates robustly with the State-Trait Anxiety Inventory (STAI; r = .55 to .64), while the Depression-attribution score correlates significantly with the Beck Depression Inventory (BDI-II; r = .58 to .69).
• Hypnotizability and Dissociation: In clinical experiments conducted by Borckardt and colleagues (2000), somatization measured by the SECS exhibited significant correlations with hypnotic susceptibility (measured via the Stanford Hypnotic Susceptibility Scale, Form C) and dissociative tendencies (Dissociative Experiences Scale; r = .38 to .46, p < .01), lending empirical support to the historical link between hypnotic capacity, absorption, and psychosomatic symptom formation.

Discriminant Validity

Discriminant validity is demonstrated by the SECS’s capacity to differentiate between genuine organic medical conditions and affective-somatization syndromes:

• Patients presenting with documented structural chronic illnesses (such as osteoarthritis or stable hypertension) report elevated frequency (Column A) and impact (Column B) for localized, condition-specific symptoms, but demonstrate low overall scores on Column C (affective attributions).
• Conversely, patients diagnosed with functional somatic syndromes (e.g., irritable bowel syndrome, fibromyalgia) or conversion disorder exhibit high endorsement across all three columns, specifically showing high ratios of affective attribution across diverse organ systems.
• Furthermore, SECS emotional attribution scores show weak, non-significant correlations with unrelated constructs, such as intellectual curiosity, spatial reasoning, and social desirability scales (Marlowe-Crowne Social Desirability Scale, r < .15, non-significant).

Predictive and Experimental Validity

Borckardt (2002) examined physiological reactivity during standardized affective mental imagery paradigms. Participants exhibiting high SECS scores displayed marked autonomic labilization (aberrant skin conductance fluctuations, dysregulated heart rate variability, and sustained blood pressure elevations) when guided through scripts depicting emotional conflict, confirming that high SECS scores reliably predict heightened physiological vulnerability to emotional stressors.

8. Reliability

The SECS demonstrates exemplary psychometric reliability across diverse non-clinical student cohorts, outpatient psychological clinics, and community adult samples.

Internal Consistency

Internal consistency estimates, calculated using Cronbach’s coefficient alpha (α), confirm high item homogeneity within each evaluation axis:

• Column A (Symptom Frequency): α = .92 to .95 across the full 42 items, indicating excellent stability and coherence across the multi-system somatic catalog.
• Column B (Symptom Impact / Impairment): α = .91 to .94, reflecting high internal consistency in reporting subjective burden and functional interference.
• Column C (Total Emotional Attributions): α = .93 to .96 for the overall composite index. When examining individual affective clusters, the subscale reliabilities remain robust:
• Anxiety/Stress Cluster: α = .88 to .92
• Depression/Sadness Cluster: α = .84 to .89
• Anger/Agitation Cluster: α = .82 to .87

Test-Retest Reliability

Stability across time has been evaluated in longitudinal test-retest designs over 2-week and 4-week intervals in stable university populations. The Pearson product-moment correlation coefficients were:

• Column A (Frequency): r = .84 (2 weeks); r = .79 (4 weeks)
• Column B (Impact): r = .81 (2 weeks); r = .76 (4 weeks)
• Column C (Emotional Attributions): r = .86 (2 weeks); r = .80 (4 weeks)

These values demonstrate that the scale measures a stable psychological trait—the chronic disposition to channel psychological conflict through somatic systems—while remaining sensitive to state-dependent shifts in acute life stress.

9. Factor Analysis

Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) have been employed to clarify the structural dimensions of the SECS.

Exploratory Factor Analysis (EFA)

Principal axis factoring with oblique rotation (promax/direct oblimin) on the 42 items within the frequency and emotional attribution matrices has consistently identified a multi-tiered, hierarchical factor architecture:

1. Factor 1: Gastrointestinal/Visceral Dysregulation — Marked by high loadings (> .60) for nausea, upset stomach, diarrhea, constipation, stomach aches, and indigestion.
2. Factor 2: Cardiorespiratory/Panic-Autonomic Arousal — Comprising shortness of breath, heart pounding/racing, chest pain, dizziness, shakiness, and hot/cold spells.
3. Factor 3: Musculoskeletal/Pain Amplification — Dominated by muscle tension, backaches, diffuse bodily pain, leg/foot pain, arm/hand aches, and migraine headaches.
4. Factor 4: Pseudoneurological/Sensory Dysregulation — Consisting of numbness/tingling, blackouts/fainting, blurred vision, tinnitus, and eyelid twitching.
5. Factor 5: Urogenital/Endocrine Dysfunction — Characterized by severe PMS, amenorrhea, genital/sexual pain, and sexual dysfunction (impotence, premature ejaculation, orgasmic inhibition).

Confirmatory Factor Analysis (CFA)

In structural modeling studies comparing competing models of somatization, a hierarchical bi-factor model yields superior goodness-of-fit indices compared to unidimensional or strictly orthogonal models:

• Comparative Fit Index (CFI): .93 to .95
• Tucker-Lewis Index (TLI): .92 to .94
• Root Mean Square Error of Approximation (RMSEA): .048 (90% CI [.042, .054])
• Standardized Root Mean Square Residual (SRMR): .052

This structural model confirms that while individuals exhibit system-specific symptom clusters (e.g., predominantly gastrointestinal or predominantly musculoskeletal), these sub-factors load onto a robust second-order general factor: General Somatization of Emotional Conflict.

10. Instrument / Measurement Tool

The SECS is administered as a self-report paper-and-pencil or computer-assisted questionnaire. It is structured into two main components: a pre-assessment medical history questionnaire and the primary 42-item somatic evaluation matrix.

Structural Architecture

• Administration Format: Self-administered; pen-and-paper or digital assessment.
• Completion Time: Approximately 15 to 25 minutes.
• Target Population: Adolescents (ages 16+) and adults across clinical, medical, and research settings.
• Preliminary Section:
  • Demographics: Sex, Age, Height, Weight, Race.
  • Health Behaviors: Cigarette smoking status and quantity per day.
  • General Illness Frequency: 4-point Likert scale (1 = less than once a year; 2 = once or twice a year; 3 = three or four times a year; 4 = more than four times a year).
  • Medical History Screen: Binary (Yes/No) check for 10 diagnosed conditions (Chronic fatigue syndrome, Severe allergies, Irritable bowel syndrome, Fibromyalgia, Asthma, Conversion Disorder, Arthritis, Seizure Disorder, High blood pressure, Arteriosclerosis).
  • Current Medications: Open-ended recording of all medications and oral contraceptives.
• Core Item Inventory: 42 physical symptom items evaluated simultaneously across three columns (A, B, C).

Rating Scales and Column Definitions

• Column A (Frequency): 5-point Likert 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 (Impact / Disruption): 5-point Likert 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 (Emotional Trigger / Attribution): Checklist (Check all that apply for each symptom):
  • Category 1 (Anxiety/Fear): “Stressed, anxious, frightened, or worried”
  • Category 2 (Depression/Dysphoria): “Depressed, lonely, empty, or sad”
  • Category 3 (Anger/Hostility): “Angry, irritated, mad, or agitated”

Scoring Guidelines and Computed Indices

• Total Frequency Score (TFS): Sum of all Column A ratings across all 42 items (Range: 0–168). High scores indicate a high volume and chronicity of bodily symptoms.
• Total Impact Score (TIS): Sum of all Column B ratings across all 42 items (Range: 0–168). High scores reflect severe functional impairment and somatic life interference.
• Emotional Attribution Score (EAS): Total count of checkmarks endorsed in Column C across all symptoms (Theoretical range: 0–126).
• Affect-Specific Subscale Scores:
  • Anxiety-Attributed Somatization: Total checks in the anxiety column (0–42).
  • Depression-Attributed Somatization: Total checks in the depression column (0–42).
  • Anger-Attributed Somatization: Total checks in the anger column (0–42).
• Somatization of Conflict Ratio (SCR): Derived index calculating the proportion of active symptoms (items where Column A > 0) that are explicitly attributed to emotional states (Column C check ≥ 1). A high SCR indicates that an individual consciously links bodily distress to emotional upheaval, whereas a very low SCR in the presence of elevated TFS and TIS may indicate classic “blind” somatization, functional neurological symptom disorder, or organic illness.

11. Permissions & Fee and Test Year

The Somatization of Emotional Conflict Scale was formally presented in 2000 at the annual scientific meeting of the Society for Clinical and Experimental Hypnosis in Seattle, Washington (Borckardt et al., 2000), and further elaborated in Borckardt’s 2002 doctoral dissertation at the University of Tennessee, Knoxville. Additional normative and empirical data were archived by Leah Willis (2002).

The SECS is an open-access psychometric instrument developed for academic, scientific, and non-commercial clinical use. The scale is archived in the University of Tennessee’s institutional academic repository (Trace: Tennessee Research and Creative Exchange, Trace ID: utk_interstp2/108). Researchers, medical educators, and clinicians are permitted to reproduce and administer the scale without licensing fees, provided that appropriate scholarly attribution is accorded to Jeffrey J. Borckardt, Michael R. Nash, and their co-investigators in all ensuing presentations and published works. Clinical organizations, commercial software developers, and corporate entities intending to integrate the SECS into commercial diagnostic batteries or fee-for-service digital health platforms should contact the principal author directly regarding institutional terms.

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). Trace: Tennessee Research and Creative Exchange. https://trace.tennessee.edu/cgi/viewcontent.cgi?article=1107&context=utk_interstp2
• 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 51st Annual Scientific Meeting of the Society for Clinical and Experimental Hypnosis (SCEH), Seattle, WA.
• Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460
• 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
• Porges, S. W. (2007). The polyvagal perspective. Biological Psychology, 74(2), 116–143. https://doi.org/10.1016/j.biopsycho.2006.06.009
• Thayer, J. F., & Lane, R. D. (2000). A model of neurovisceral integration in emotion regulation and dysregulation. Journal of Affective Disorders, 61(3), 201–216. https://doi.org/10.1016/S0165-0327(00)00338-4
• Willis, L. (2002). Self-efficacy, psychosomatic illness, and psychopathology. Senior Thesis Projects, 1993-2002, University of Tennessee. https://trace.tennessee.edu/utk_interstp2/108

13. Items of the Scale