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J Psychosom Res. 2014 Feb;76(2):94-8. doi: 10.1016/j.jpsychores.2013.11.019. Epub 2013 Dec 9.

Struggling in an emotional avoidance culture: a qualitative study of stress as a predisposing factor for somatoform disorders.

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Department of Clinical Medicine, Aarhus University, Denmark; Department of Psychology and Behavioural Sciences, Aarhus University, Denmark. Electronic address:
Department of Clinical Medicine, Aarhus University, Denmark; Department of Public Health, Section for Nursing, Aarhus University, Denmark.
Department of Psychology and Behavioural Sciences, Aarhus University, Denmark.



To explore patterns of experienced stress and stress reactions before the onset of illness in the life history of patients with severe somatoform disorders to identify predisposing stress-mechanisms.


A systematic, thematic analysis was conducted on data collected from 24 semi-structured individual life history interviews.


Generally, patients had experienced high psychosocial stress during childhood/youth. However, there was considerable variability. Characteristic of all patients were narrations of how communication with significant adults about problems, concerns, and emotions related to stress were experienced to be difficult. The patients described how this involved conflicts stemming from perceived absent, insufficient, or dismissive communication during interactions with significant adults. We conceptualized this empirically based core theme as "emotional avoidance culture." Further, three related subthemes were identified: Generally, patients 1.) experienced difficulties communicating problems, concerns, and related complex feelings in close social relations; 2.) adapted their emotional reactions and communication to an emotional avoidance culture, suppressing their needs, vulnerability and feelings of sadness and anger that were not recognized by significant adults; and 3.) disconnected their stress reaction awareness from stressful bodily sensations by using avoidant behaviors e.g. by being highly active.


Patients adapted to an emotional avoidance culture characterized by difficult and conflicting communication of concerns and related emotions in social interactions with significant adults. Patients experienced low ability to identify and express stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact, which made them vulnerable to stressors. Generally, patients resolved stress by avoidant behaviors, prolonging their stress experience.


Experienced stress; Life history; Qualitative research; Social interaction; Somatoform disorders; Stress reactions

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