Somatoform Disorders - download.e-bookshelf.de€¦ · Somatoform Disorders Editors Mario Maj University of Naples, Italy Hagop S. Akiskal University of California, San Diego, USA

VOLUME

9Somatoform Disorders

Editors

Mario MajUniversity of Naples, Italy

Hagop S. AkiskalUniversity of California, San Diego, USA

Juan E. MezzichMount Sinai School of Medicine, New York, USA

Ahmed OkashaAin Shams University, Cairo, Egypt

WPA SeriesEvidence and Experience in Psychiatry

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VOLUME



Other Titles in the WPA SeriesEvidence and Experience in

PsychiatryVolume 1—Depressive Disorders 1999

Mario Maj and Norman SartoriusISBN 0471999059

Depressive Disorders, Second Edition 2003Mario Maj and Norman Sartorius

ISBN 0470849657

Volume 2—Schizophrenia 1999Mario Maj and Norman Sartorius

ISBN 0471999067

Schizophrenia, Second Edition 2003Mario Maj and Norman Sartorius

ISBN 0470849649

Volume 3—Dementia 1999Mario Maj and Norman Sartorius

ISBN 0471606987

Dementia, Second Edition 2003Mario Maj and Norman Sartorius

ISBN 0470849630

Volume 4—Obsessive-Compulsive Disorder 1999Mario Maj, Norman Sartorius, Ahmed Okasha and Joseph Zohar

ISBN 047187163X

Obsessive-Compulsive Disorder, Second Edition 2003Mario Maj, Norman Sartorius, Ahmed Okasha and Joseph Zohar

ISBN 0470849665

Volume 5—Bipolar Disorder 2002Mario Maj, Hagop S. Akiskal, Juan José López-Ibor and Norman Sartorius

ISBN 0471560375

Volume 6—Eating Disorders 2003Mario Maj, Katherine Halmi, Juan José López-Ibor and Norman Sartorius

ISBN 0470848650

Volume 7—Phobias 2004Mario Maj, Hagop S. Akiskal, Juan José López-Ibor and Ahmed Okasha

ISBN 0470858338

Volume 8—Personality Disorders 2005Mario Maj, Hagop S. Akiskal, Juan E. Mezzich and Ahmed Okasha

ISBN 0470090367

Volume 9—Somatoform Disorders 2006Mario Maj, Hagop S. Akiskal, Juan E. Mezzich and Ahmed Okasha

ISBN 0470016124

VOLUME


Editors

Mario MajUniversity of Naples, Italy

Hagop S. AkiskalUniversity of California, San Diego, USA

Juan E. MezzichMount Sinai School of Medicine, New York, USA

Ahmed OkashaAin Shams University, Cairo, Egypt


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Contents

List of Review Contributors xiii

Preface xv

CHAPTER 1 SOMATIZATION AND CONVERSIONDISORDERS 1

Somatization and Conversion Disorders: A Review 1Harold Merskey and François Mai

COMMENTARIES1.1 From Hysteria to Somatization 23

Francis Creed1.2 Somatoform and Conversion Disorders or Somatic

Presentations of Mental Disorders? 26Javier I. Escobar

1.3 Are Somatoform Disorders a Distinct Category? 29Gregory E. Simon

1.4 Somatoform Disorders: Deconstructing a Diagnosis 31Oye Gureje

1.5 The Psychobiology of Somatization and ConversionDisorders 34

C. Robert Cloninger and Mehmet Dokucu1.6 Patient or Process? 38

Linda Gask1.7 Reading the Body? 40

Leslie Swartz1.8 Somatization and Conversion Disorders: A

Forgotten Public Health Agenda? 42Shekhar Saxena

1.9 A Cognitive Account on Conversion andSomatization Disorders 44

Karin Roelofs1.10 Labelling the Unfathomable 47

Bart Sheehan

vi CONTENTS

1.11 Somatization and Conversion: An OngoingControversy 50

Carsten Spitzer and Hans Jörgen Grabe1.12 The Mind–Body Dualism and Conversion Disorders 52

Carlo Faravelli and Massimo Lai1.13 Concepts of Medically Unexplained Symptoms in

Relation to Mind-Body Dualism 55Athula Sumathipala

1.14 A Challenge for Both Clinicians and Researchers 57Antonio Lobo

1.15 Somatization Disorders in the African Context 59Frank G. Njenga, Anna N. Nguithi and RachelKang’ethe

1.16 Somatization and Conversion Disorders: An ArabPerspective 62

Tarek A. Okasha1.17 Much Theory, but Little Agreement 65

Alberto Perales and Héctor Chue

CHAPTER 2 PAIN DISORDER 67

Pain Disorder: A Review 67Steven A. King

COMMENTARIES2.1 The Major Paradigm Shift from the Biomedical

Reductionist to the Biopsychosocial Approach to theAssessment and Treatment of Pain 93

Robert J. Gatchel2.2 DSM and Pain: When (if Ever) Is Pain Truly a

Psychiatric Disorder? 96Robert Boland

2.3 Pain Disorder or Just Pain: Can We Escape Dualism? 98Robert G. Large and Tipu Aamir

2.4 The Mind–Body Dichotomy in the Modern World 101Hans Jörgen Grabe and Carsten Spitzer

2.5 Chronic Pain: Towards a BiopsychosocialPerspective 102

Michael Bach and Martin Aigner2.6 Pain Disorder: Where’s the Utility? 105

Lance M. McCracken2.7 Patients Must Be at the Centre of Pain Management 107

Joanna M. Zakrzewska

CONTENTS vii

2.8 Chronic Pain: the Importance of a ComprehensiveHistory 110

Gerald M. Aronoff2.9 Psychological and Physiological Factors in Pain

Disorder 112Morten Birket-Smith

2.10 Does the Somatoform Disorder Approach BroadenOur Perspective on Pain? 114

Wolfgang Hiller and Paul Nilges2.11 Diagnosis and Treatment of Pain:

Consultation-Liaison Psychiatry Aspects 117Albert Diefenbacher

2.12 Pain: Suffering, Semantics, and Sensitization 119Jeffrey Rome

2.13 Subjectivity and Communitas: FurtherConsiderations on Pain 121

Etzel Cardeña2.14 The Relationship Between Pain and Anxiety

Disorders 123Antonio Bulbena, Carlos Garcia Ribera and Lili Sperry

2.15 Gaps in Evidence Base of Pain Disorders 125Santosh K. Chaturvedi

2.16 Pain in General Practice 127Manuel Suarez Richards and GustavoAlfredo Delucchi

CHAPTER 3 HYPOCHONDRIASIS 129

Hypochondriasis: A Review 129Russell Noyes Jr.

COMMENTARIES3.1 Hypochondriasis: Future Directions in Classification

and Etiology Research 161Steven Taylor and Gordon J.G. Asmundson

3.2 Making Sense of Hypochondriasis 164Jonathan S. Abramowitz

3.3 Hypochondriasis: An Endless Source ofControversies? 167

Vladan Starcevic3.4 Hypochondriasis: Defining Boundaries, Exploring

Risk Factors and Immunology 170Eamonn Ferguson

viii CONTENTS

3.5 Hypochondriasis, Health Anxiety, andCognitive-Behavioural Therapy 172

Patricia Furer and John R. Walker3.6 Progress with Hypochondriasis 174

Theo K. Bouman3.7 The Clinical Spectrum of Hypochondriacal Fears

and Beliefs 177Giovanni A. Fava and Stefania Fabbri

3.8 A Nosological Nightmare 179Geoffrey G. Lloyd

3.9 Hypochondriacal Syndromes: Where Did They Go? 181Driss Moussaoui

3.10 Dimensional versus Categorical Approach toObsessions, Delusions, and Hypochondriasis 183

Joseph Zohar3.11 The Nosographic Complexity of Hypochondriasis

and the Ambiguity of the Body 185Héctor Pérez-Rincón

3.12 Hypochondriasis: Is There a Promising Treatment? 187Tewfik K. Daradkeh

CHAPTER 4 BODY DYSMORPHIC DISORDER 191

Body Dysmorphic Disorder:A Review 191

Giulio Perugi and Franco Frare

COMMENTARIES4.1 The Complexity of Body Dysmorphic Disorder 222

Vilma Gabbay and Rachel G. Klein4.2 Preoccupation with Appearance: Limitations of Our

Understanding and Treatment 224Jon E. Grant

4.3 Translational and Evolutionary Models of BodyDysmorphic Disorder 226

Dan J. Stein4.4 Our Evolving Understanding of Body Dysmorphic

Disorder 228Nancy J. Keuthen and Antje Bohne

4.5 Is Body Dysmorphic Disorder a CulturallyDetermined Expression of a Body Image Disorder? 231

David H. Gleaves and Suman Ambwani

CONTENTS ix

4.6 Body Dysmorphic Disorder: Awareness Needed 233Don E. Jefferys

4.7 Recent Findings in Body Dysmorphic Disorder andFuture Directions 235

Sabine Wilhelm and Ulrike Buhlmann4.8 Body Dysmorphic Disorder: Some Issues

Concerning Classification and Treatment 237Fugen Neziroglu

4.9 Body Dysmorphic Disorder: The Antithesis ofNarcissus 240

Andrew A. Nierenberg4.10 Playing the Devil’s Advocate: Is the Concept of

Delusional Disorder, Somatic Type, Condemned toExtinction? 241

Leonardo F. Fontenelle, Mauro V. Mendlowicz andMarcio Versiani

4.11 Advancing the Understanding of Body DysmorphicDisorder 244

Eric Hollander and Bernardo Dell’Osso4.12 Is Body Dysmorphic Disorder More than a DSM

Construct? 247Michel Botbol

4.13 Body Dysmorphic Disorder andObsessive–Compulsive Disorder: More Similaritiesthan Differences 249

Euripedes C. Miguel, Albina R. Torres and YgorA. Ferrão

CHAPTER 5 CHRONIC FATIGUE AND NEURASTHENIA 253

Chronic Fatigue and Neurasthenia:A Review 253

Michael C. Sharpe and Simon Wessely

COMMENTARIES5.1 From Neurasthenia to Chronic Fatigue Syndrome: A

Journey, Not a Destination 285Kurt Kroenke

5.2 Tired People Challenge Medicine 287Stefan Priebe

5.3 Disease, Sickness or Illness: Which One Is ChronicFatigue Syndrome and/or Neurasthenia? 291

Bedirhan Ustun

x CONTENTS

5.4 Constructing Chronic Fatigue: Empiricism,Psychiatry, and Sociocultural Contexts 294

Renée R. Taylor5.5 Chronic Fatigue Syndrome as a Paradigm for

Psychosomatic Medicine 297James L. Levenson

5.6 Beyond Fashion 299Gordon Parker

5.7 Chronic Fatigue and Disembodied DSM 302Sing Lee and Arthur Kleinman

5.8 Problems of Definition, Etiological Approaches andIssues of Management in Chronic FatiguingDisorders 305

Anne Farmer and Tom Fowler5.9 Chronic Fatigue Syndrome: Time to Concentrate on

Fatigue, Not Chronicity 308Petros Skapinakis and Venetsanos Mavreas

5.10 Chronic Fatigue Syndrome: A Real Disease, A RealProblem 311

Jonathan R. Price5.11 The Specificity of Chronic Fatigue, Neurasthenia,

and Somatoform Disorders 313Winfried Rief

5.12 Chronic Fatigue in Developing Countries 316Vikram Patel

5.13 Functional Somatic Syndromes: Many Names for theSame Thing? 319

Marco Antonio Brasil, José Carlos Appolinário andSandra Fortes

5.14 Recent Developments in Chronic Fatigue Syndrome 321Ruud C.W. Vermeulen

5.15 Does Neurasthenia Really Exist in this Century? 323Edmond Chiu

CHAPTER 6 FACTITIOUS PHYSICAL DISORDERS 325

Factitious Physical Disorders:A Review 325

Stuart J. Eisendrath and John Q. Young

COMMENTARIES6.1 Wilful Deception as Illness Behaviour 352

Christopher Bass

CONTENTS xi

6.2 Factitious Disorders: Diagnosis or Misbehaviour? 354Charles V. Ford

6.3 Factitious Disorder and Malingering: The Doctor’sDilemma 358

Stephen M. Lawrie and Michael C. Sharpe6.4 Factitious Physical Disorders: The Challenges of

Efficient Recognition and Effective Intervention 360Lois E. Krahn

6.5 Some Aspects of Factitious Physical Disorders byProxy 363

Christopher Cordess6.6 Inventing Illness: The Deviant Patient 366

Don R. Lipsitt6.7 Characterizing Factitious Physical Symptoms 369

David G. Folks6.8 Moral Constraints, Regret, and Remorse in Treating

Patients with Factitious Disorder 372Ovidio A. De León

6.9 Fact, Fiction, Factitious, or Fractious Disorders 375Dinesh Bhugra

6.10 Factitious Physical Disorders: A Strategy of Survivalfor Medically Trained Traumatized Borderlines? 376

Ramon Florenzano6.11 Factitious Physical Disorders and Malingering: The

Hazardous Link 378Saı̈da Douki, Sara Benzineb and Fathy Nacef

Index 381

List of Review Contributors

Stuart Eisendrath Langley Porter Psychiatric Hospital and Clinics, Univer-sity of California at San Francisco, 401 Parnassus Avenue, San Francisco,CA 94143-0984, USA

Franco Frare Adults Mental Health Unit, Pistoia Zone, Pistoia, Italy

Steven A. King New York University School of Medicine, 308 E. 38th St.,#19A, New York, NY 10016, USA

François Mai Department of Psychiatry, Ottawa General Hospital, MedicalAdvisory Unit, 355 River Road, Ottawa, Ontario, K1A 0L1, Canada

Harold Merskey University of Western Ontario, 71 Logan Avenue, Lon-don, Ontario, N5Y 2P9, Canada

Russell Noyes Jr. Psychiatry Research, Medical Education Building, IowaCity, IA 52242-1000, USA

Giulio Perugi Department of Psychiatry, University of Pisa, Via Roma 67,56100 Pisa, Italy

Michael C. Sharpe School of Molecular and Clinical Medicine and Symp-toms Research, The Kennedy Tower, Royal Edinburgh Hospital, EdinburghEH10 5HF, UK

Simon Wessely King’s Centre for Military Health Research, Institute ofPsychiatry, King’s College London, Weston Education Centre, CutcombeRd., London SE5 9RJ, UK

John Q. Young Langley Porter Psychiatric Hospital and Clinics, Universityof California at San Francisco, 401 Parnassus Avenue, San Francisco, CA94143-0984, USA

Preface

This book reviews one of the most controversial and challenging areas ofmodern psychiatry. In fact, patients who present with somatic symptoms thatremain ‘‘medically unexplained’’ pose a variety of conceptual and practicalproblems.

First of all, they bring along the issue of Cartesian mind–body dichotomy, aconceptual frame that has been frequently criticized, but keeps on influencingour thinking and our nosology. This issue recurs in all the chapters of thebook. In the chapter on pain disorder, several contributors emphasize thedifficulty in evaluating, as requested by the DSM-IV, the relative role ofphysical and psychological factors in the genesis of pain, and underline theinadequacy of such a dualistic approach. In the chapter on somatization andconversion disorders, the high rate of neurological illness in patients receivingthe diagnosis of conversion disorder is repeatedly emphasized. In the chapteron chronic fatigue and neurasthenia, the continuing oscillations between apredominantly biological and a predominantly psychogenic interpretation ofthe disorder, and their social and ‘‘political’’ implications, are clearly shown.The fact that both medically explained and medically unexplained somaticsymptoms are frequently associated with mood and anxiety disorders ismentioned as a further evidence of the uncertainty of the boundary betweenthe two categories of symptoms.

The frequent ‘‘comorbidity’’ between somatoform disorders and othermental disorders (especially mood and anxiety disorders) poses the prob-lem of whether the former category should be kept separate or should besubsumed under other diagnostic headings. This issue emerges in almostall the chapters of the book, in particular, in the discussion concerning therelationship between hypochondriasis and anxiety disorders, between bodydysmorphic disorder and obsessive–compulsive disorder, and between som-atization disorder and major depression. Many psychiatrists might suggestthat somatization is an integral part of several mental disorders or an alterna-tive manifestation of mood or anxiety disorders. However, in many instances,irrespective of one’s nosological assumptions, a clinical presentation withsomatoform manifestations does raise therapeutic challenges beyond a clas-sical mood or anxiety disorder. This may well be the reason why cliniciansworking in the interface of psychiatry and medicine find the concept ofsomatoform disorders still useful.

xvi PREFACE

The uncertainty of the boundary between conscious and unconsciousproduction of somatic symptoms and signs, and the frequent switch ofthe same patient from unconscious ‘‘hysterical’’ behaviour to deliberatedeception, is emphasized in the chapter on factitious disorders. This providesa rationale for the inclusion of these disorders in the volume, despite the factthat they are separated from somatoform disorders in current classificationsystems.

On the practical side, the frustration often experienced by physicians whenconfronted with somatoform disorders and, at the same time, the need toestablish an effective therapeutic relationship, including a legitimation ofthe patient’s symptoms, represents a recurring theme in the volume. Themessage that ‘‘management begins with examination’’ (i.e., managementbegins by showing that the time spent in history taking and examination isproportionate to the importance of the symptoms to the patient) is probablythe one that emerges most frequently from the various chapters. The need fora sustained involvement of the physician and an ongoing health monitoringis repeatedly emphasized, as well as the requirement of the patient’s activecollaboration for the success of cognitive–behavioural therapy.

The comparison with the other volumes of the series ‘‘Evidence andExperience in Psychiatry’’ shows that somatoform disorders have beena relatively infrequent target for randomized controlled trials, both onthe psychotherapeutic and the psychopharmacological sides, which clearlycontrasts with their high prevalence and the very significant financial andemotional burden they place on the community. Probably due to this, andto the above-mentioned conceptual and practical problems posed by thesedisorders, the ‘‘experience’’ (as opposed to ‘‘evidence’’) component of thisbook is more substantial than in the other volumes of the series. This inputmay represent a stimulus for innovative research planning.

The geographic representation in the authorship of this book is evenbroader than in the other volumes of the series: the contributors are from35 different countries, representing all the continents and all the geographiczones of the WPA. This reflects the importance of the cultural dimension inthe development and manifestation of somatoform disorders and emphasizesthe need to take this dimension into account in future approaches to theirdiagnosis and classification. The paper on the diagnosis of neurastheniain China is particularly instructive in this respect, as are the reports onsomatization disorders from Arab countries.

The readership of this book is expected to be slightly different from thatof the other volumes of the series, including not only psychiatrists and othermental health workers, but also general practitioners and other medicalspecialists. These colleagues will probably appreciate the clinical orientationof all the chapters of the book and the deliberate attempt to avoid the use ofa strictly psychiatric jargon.

PREFACE xvii

It is our hope that this volume will be useful to psychiatric and non-psychiatric professionals in their clinical practice and will contribute sig-nificantly to the ongoing debate on this challenging area of psychiatry andpublic health.

Mario MajHagop S. Akiskal

Juan E. MezzichAhmed Okasha

CHAPTER

1Somatization and Conversion

Disorders: A Review

Harold Merskey1 and François Mai21University of Western Ontario, 71 Logan Avenue, London, Ontario, N5Y 2P9, Canada

2Department of Psychiatry, Ottawa General Hospital, Medical Advisory Unit, 355 RiverRoad, Ottawa, Ontario, K1A 0L1, Canada

INTRODUCTION

Most bodily symptoms in the present categories of somatization fall into twogroups. One group comprises symptoms that are involuntary and automatic,depending on arousal in the autonomic nervous system. They often appearwith depression as well as anxiety. The second group of symptoms dependsupon thoughts or embodies intentions, and yet these thoughts and ideas arenot recognized, or are not acknowledged, by the patient. In discussing thistopic, it helps to distinguish these two groups of symptoms both phenomeno-logically and aetiologically. Allocating a symptom to the second group,however, may be difficult because, sometimes, autonomic symptoms canbe adopted and utilized as reflecting ideas. Cardiac palpitations are a goodexample, particularly if associated with chest discomfort. In that case whatperhaps begins as an autonomic response may become a response, or a cog-nitive event, permitting retreat or escape from a difficult cognitive problem.

Because our present notions exist in a changing framework of conceptsand observations, it helps to discuss the meaning of the physical symptomsof psychological origin as it has evolved sequentially. We begin with theterm hysteria, which is much older than conversion disorder, which in turnis older than somatization.

HISTORICAL BACKGROUND

The recognition of hysterical symptoms is thought to date back to Hip-pocrates. The evidence for this is limited. The Hippocratic Collection of

Somatoform Disorders. Edited by Mario Maj, Hagop S. Akiskal, Juan E. Mezzich and Ahmed Okasha 2005 John Wiley & Sons, Ltd

2 SOMATOFORM DISORDERS

writings contains a number of entries that describe treatments that wouldassist the womb to return to its place. Sometimes these treatments wereprovided from below, that is, through the vagina, and sometimes theywere provided from above, whether through the nostrils or as liquids.Medieval theorists held that the Greeks believed in a migration of the womb,downwards or upwards, sometimes by virtue of unsatisfied sexual drive.Historians, for example Veith [1], wrote that these ideas were obtained fromthe ancient Egyptians, but re-reading the available texts from the Papyri thatwere supposed to provide this information leaves considerable doubt as towhether the Egyptians had such ideas at all [2], and claims about the Greekbelief are also uncertain.

There is no full English version of the Hippocratic Collection, but theFrench version by Littré [3] described several phenomena that could be diag-nosed as ‘‘hysterical’’, including hysterical suffocation (‘‘hysterike pnix’’).This phenomenon gave rise to the idea that the womb could move aroundthe body, block the channels of respiration and cause ‘‘suffocation’’. How-ever, King [4] pointed out that the Littré translation introduced headings toorganize the concept of hysteria as hysterical suffocation, an organizationabsent from the original material. Micale [5] remarked that the Littré editioncontains ‘‘no coherent clinical syndrome in the modern sense but only themost casual enumeration of symptoms including laboured breathing, lossof voice, neck pain, heart palpitations, dizziness, vomiting, and sweating’’and that there was no clear reference to globus hystericus or hyperesthe-sia. King [4] further noted that ‘‘suffocation of the womb’’ was probablyan incorrect translation, and that the original Greek ‘‘hysterike pnix’’ morelikely means stifling and implies heat as well as difficulty in breathing.

Galen, the leading anatomist of ancient times, concluded that the wombwas fixed and did not move about the body. It seems that the descriptionsof the womb moving around were a dramatic elaboration of the fact thatsometimes the womb might swell, as in pregnancy, or drop, as in prolapse.

Supposedly, hysterical symptoms could come and go and often did moveaway, or return under the influence of particular psychological circum-stances, so that the idea developed that they might be due to witchcraft.This idea was widespread through Europe. Protestant pastors, like RomanCatholic priests, exorcised devils to cure distressed young women [6]. Char-cot, as an early nineteenth-century neurologist, was similarly keen to showthat medicine could provide a better explanation of ‘‘possession’’ than theChurch [7].

An explanation of hysterical symptoms as a consequence of psychologicaltrauma was provided by Sydenham [8], the leading British physician of hisday: ‘‘When the mind is disturb’d by some grevious Accident, the animalSpirits run into disorderly motions. . . .Whatsoever part of the body theDisease doth affect (and it affecteth many) immediately the symptoms that

SOMATIZATION AND CONVERSION DISORDERS: A REVIEW 3

are proper to that Part appear; in the Head, the Apoplexy, which ends in aPalsy of one half of the Body. . . sometimes they are seiz’d with Convulsions,that very much resemble the Epilepsy. . . At other times they are miserablytormented with the Hysterical Clavus [nail], in which there is a most vehementpain in the Head. . .’’. Sydenham mentioned other pains in addition to thehysterical clavus, and also diarrhoea, dropsy (oedema), tears, and laughter.Nowadays, we would recognize some of these changes as due to the presenceof brain damage or as related to anxiety or depression.

According to Micale [5], ‘‘In the 18th century the disorder slid impercep-tibly into hypochondria, the vapours, and in the 19th century it often over-lapped with neurasthenia, nymphomania, general nervousness. . . Many. . .have used the word in reference to any nervous malady with convulsivecomplications. . . Many physicians have complained vociferously about thevagueness and indefinability of hysteria’’.

By the mid-nineteenth century, the concept of hysteria involved numerousbodily symptoms, often with episodic exacerbations [9, 10]. By the time ofPaul Briquet [11], hysteria was considered to be a life-long disorder, cerebralin origin, almost always found in young women, characterized by painsin any part of the body, paralysis of limbs, anaesthesias, certain types offits, dyspnea, pharyngeal globus, dysphagia, hiccup, vomiting, meteorism,dysuria, and urinary retention. Briquet published an extensive clinical anddemographic study [12, 13] and described the clinical patterns in detail underseven headings. He associated the disorder with a ‘‘neurosis of the brain’’and emphasized the importance of heredity. More astutely, Sir BenjaminBrodie [14] observed that there was no clear organic cause for hystericalcomplaints but ‘‘. . .it is not the muscles which refuse to obey the will, but thewill itself which has ceased to work’’.

Ideas about hysteria fluctuated during the nineteenth century. This is theperiod, however, in which many of our existing concepts seem to have grownstrong. In particular, there was an increasing recognition of the fact that so-called hysterical symptoms appeared to be related to ideas. The first to bringthis out explicitly was Sir John Russell Reynolds [15], and his views werequickly adopted and assimilated by Charcot, the leading French neurologistof his day. These insights were stimulated by increasing neurological skill inthe evaluation of symptoms.

Sigmund Freud made the last apparent major nineteenth century contri-bution to hysteria by explaining physical symptoms that seemed to be dueto the loss of the patient’s will as caused by the repression of ideas into theunconscious. That view is now vigorously challenged because of increasingdoubts about the value of psychoanalysis, its lack of empirical support, andeven the truthfulness of Freud’s original accounts [16, 17].

The term somatization is more recent. Wilhelm Stekel [18] wrote of‘‘organspräche’’, or ‘‘organ speech’’, which was translated as ‘‘somatization’’,


possibly a mistranslation [19]. The word became popular when Lipowski [20]offered a definition that he later amended to read ‘‘the tendency to expe-rience and communicate somatic distress and symptoms unaccounted forby pathological findings, to attribute them to physical illness and to seekmedical help for these’’ [21].

THE CONCEPT OF CONVERSION DISORDER

The central issue in understanding and appraising physical symptoms withpresumed psychological causes concerns the nature of their development.Are they a consequence of psychophysiological events, or do they followfrom a process through which ideas give rise to complaints? The way inwhich the latter conclusion is reached depends particularly on neurologicalexamination. For example, if a patient reports that he or she cannot movea leg, the neurologist who tests motor power will determine if there areobvious signs of physical difficulty, for example, spasticity, clonus, a positiveBabinski test or signs of parkinsonism and extra-pyramidal rigidity, or aflaccid paralysis, as after spinal cord injury. If the limb appears to be healthy,but is still unable to move, the neurologist will undertake a proceduresuch as the Hoover test, in which one hand is placed under the affectedheel and the patient asked to lift the leg or press down, and no responseis found. Thereafter, the patient will be asked to lift the good leg whilethe hand remains under the original heel. If there is motor power in theleg where the patient thinks it has been lost, the synergistic action ofthe musculature will cause the patient to press down with the supposedlyparalysed leg and the pressure will be felt by the examining hand underneaththe heel. This kind of evidence was called positive signs of hysteria byHead [22].

In the case of the special senses, it is relatively easy to establish positivetests of visual or auditory function that will belie the patient’s claims. Withother sensory conditions, the commonest error is to attribute regional painor regional loss of sensation to hysterical mechanisms. Regional symptomsmay correspond to an idea in the mind of the patient and for this reasondiffuse anaesthesia or a regional pain in a limb were taken as an example ofhysterical complaints. Increasing knowledge has shown that pain interfereswith light touch and other cutaneous sensations and that both pain andlight touch may have a regional distribution resulting from alterations in theactivity of the nervous system. While some anaesthetic lesions correspondto dermatomal distributions or nerve root patterns, other patterns of painoften develop from organic disease. This happens also with pain affectingthe musculature, or with pain affecting a limb, so that the appearance of aregional pain due to thoughts may be mimicked although the physiologicalsituation is abnormal [23].


The late Patrick Wall and many of his colleagues working on the neu-rophysiology of pain repeatedly demonstrated that the spread of regionalpain and sensitivity to noxious stimulation or light touch could be linkedwith pathophysiological mechanisms (24, 25). A number of physical signshave been said to be ‘‘non-organic’’ in patients with musculoskeletal com-plaints, but Gordon Waddell [26], who extensively investigated these signs,reached the conclusion that they could not be taken as particular evidenceof psychological illness and were more likely to be related to severity ofpain.

The diagnosis of conversion disorder has been complicated by many extra-neous impressions, in addition to the difficulty in obtaining consistency as towhat is meant by the condition. Concepts such as belle indifférence, meaningthat the patient seems to be not bothered about a disabling symptom, werepopular because they seemed to fit well with a psychodynamic explana-tion. Since the symptoms solved the problem, the patient would feel happy.But often patients do not feel happy and some leading examples of belleindifférence probably involved patients with multiple sclerosis who sufferedfrom difficulties in movement that were thought to be psychological and hadfrontal lobe lesions that left them more happy than the average patient withparalysis [27, 28].

Gould et al. [29] examined 30 patients with acute neurological illness (29of them with stroke) and noted the evidence for seven supposedly typicalmarkers of hysteria in these patients. The seven markers were as follows:a history suggestive of hypochondriasis, potential secondary gain, belleindifférence, non-anatomical patchy sensory loss, changing boundaries ofhypoalgesia, sensory loss (to pinprick or vibratory stimulation) that splits atthe midline, and giveaway weakness. The mean number of positive itemsper patient was 3.4. It was evident that none of these items could provide aconsistently reliable basis for diagnosis.

There is still a dispute as to whether some tonic contractions may beregarded as due to conversion disorder, particularly if they are not associatedwith other signs that may be organic, and if they occur in some situationswhere potential benefit may accrue to the patient from being disabled. Thisargument arises about ‘‘writer’s cramp’’ and the repetitive pain syndromesthat may be found in workers using computers. The commonest currentinterpretation seems to be that repetitive use syndromes are better regardedas aberrant habits of muscular usage than as being due to a motivated loss ofuse or function.

It is generally accepted that classical conversion disorders are now rarein developed societies. When they occur, they are most often diagnosed(whether correctly or otherwise) in individuals who have compensationclaims, or who find themselves in difficult social situations. In developingsocieties, classical conversion disorder persists [30].


The diagnosis, and even the terminology for hysteria, has been disputedover many years. The word was rejected in DSM-III and avoided thereafterin ICD-9 and ICD-10, but still figures commonly in historical writings andin the topics favoured by social historians. Instead of hysteria, it has becomecustomary to write of conversion disorders, that is, those involving bod-ily complaints, and dissociative disorders, that is, those involving loss ofthe mental function, particularly, memory or awareness of special events.Dissociative disorders are dealt with elsewhere in this series, but the sameprinciples apply to their labelling (which will be in need of change) asthey apply here to the labelling of conversion disorders. They too can beunderstood to reflect ideas that patients have about their condition.

In response to difficulties with theories of repression affecting the con-cepts of both conversion disorders and dissociative disorders, Merskey [31]suggested that we should use the term ‘‘doxogenic disorders’’ for boththe groups. This term refers to complaints caused by having the idea of aparticular symptom or disorder. A more neutral term, ‘‘doxomorphic disor-ders’’ [32], might be further preferred since it merely indicates complaintshaving the form of a symptom related to an idea.

THE CONCEPT OF SOMATIZATION DISORDER

As originally described in DSM-III, somatization disorder was based uponthe earlier work of Cohen et al. [33] and Perley and Guze [34]. The manualrequired a history of many physical complaints over several years, beginningbefore age 30. The patient had to have sought treatment or shown significantimpairment in social, occupational or other important areas of functioning,and had to present at least 14 symptoms if female and 12 if male, froma list of 37 items. Symptoms had to be found in each of seven groups:feeling sickly, conversion or pseudo-neurological symptoms, gastrointestinalsymptoms, female reproductive symptoms, psychosexual symptoms, pain,and cardiopulmonary symptoms.

The DSM-IV criteria for somatization disorder are much less stringent.There have to be four pain symptoms related to at least four different sites,two gastrointestinal symptoms other than pain, one sexual symptom otherthan pain, and one pseudo-neurological symptom or deficit suggesting aneurological condition not limited to pain. The symptoms are not to be fullyexplicable by a known general medical condition or the direct effects of asubstance. When there is a related general medical condition, the physicalcomplaints or resulting social occupational impairment have to be in excess ofwhat would be expected from the history, physical examination or laboratoryfindings. The symptoms are not to be produced by a factitious disorder ormalingering. The history of physical complaints should begin before age 30,occurring over a period of several years and resulting in treatment being


sought or significant impairment occurring in social, occupational or otherimportant areas of functioning.

ICD-10 requires ‘‘cases’’ of somatization disorder to show at least twoyears of multiple and variable physical symptoms for which no adequatephysical explanation has been found, persistent refusal to accept the adviceor reassurance of several doctors, and some degree of impairment of socialand family function attributable to the nature of the symptoms and resultingbehaviour. This classification does not provide a cut-off for the diagnosis. Thisis not necessarily an undesirable approach to providing diagnostic guidelines.

The concept of somatization disorder remains controversial. According toKirmayer [35], somatization is neither a discrete clinical entity nor the result ofa single pathological process, but cuts across diagnostic categories. Kirmayerand Robbins [36] proposed three operational definitions of somatization:a) high levels of functional somatic distress, measured by a somatic symptomindex; b) hypochondriasis, measured by high scores on a measure of illness,worry, and the absence of evidence of serious illness; c) exclusively somaticpresentations among patients with current major depression or anxiety. Thethree forms of somatization are associated with different sociodemographicand illness behaviour characteristics. The majority of patients meet criteria foronly one type of somatization, suggesting that distinct pathogenic processesmay be involved with each of the three types. In addition, somatizationappears to be more, rather than less, likely in the presence of organic disease.

According to Merskey [23], in clinical practice and in research reports, theterm somatization is evidently used in a variety of ways, which can be sum-marized approximately as follows: a) somatization disorder; b) conversionsymptoms; c) hypochondriasis; d) heightened bodily awareness (alerting)resembling hypochondriasis but, unlike the latter, responding to reas-surance on examination or investigation; e) psychophysiological eventsassociated with anxiety or depression; f) certain types of somatic complaintsin schizophrenic patients, perhaps with a delusional basis, for examplehypochondriacal psychosis; g) any of the above, combined with organicdisease. This variety of meanings rivals the number of meanings or subdi-visions that have historically been offered for hysteria, despite the fact thatsomatization is a far younger term.

EPIDEMIOLOGY OF CONVERSION DISORDER

A study of the incidence of hysterical neurosis, conversion type, or conversiondisorder in terms of DSM-III, compared findings in Monroe County, NewYork, and in Iceland, based upon the same 10 years [37]. In Monroe County,a retrospective examination of case records from hospitals and practitionerswas undertaken, while the Icelandic figures were taken from a psychiatricregister. The overall rate in Monroe County was 22/100,000 per annum,


while in the second half of the period it was only 15/100,000 per annum.In Iceland, the rate was 11/100,000 per annum. The rate fell year by yearthroughout the 10 years in Monroe County, and there was a small similarchange in the annual rates in the Icelandic figures. In both the countries,it was thought that the continuing fall in the rates might have been partlyinfluenced by increasing scepticism with respect to the diagnosis of hysteria.The rates were twice as high for men as for women in Monroe County andalmost 5 times as high for women in Iceland.

A third group of subjects was also studied, namely, a series of 64 patientsseen in the psychiatric service of a university general hospital whose recordswere also examined for the same time period, 1960–1969. Among theseindividuals with diagnoses of hysterical neurosis, conversion type, or aconversion disorder, 39 had pain and 32 were overtly or covertly depressed.Eight were considered to be misdiagnosed.

A good prognosis is reported from developing countries [30, 37], while,in Western society and tertiary practice, patients tend to have a poor prog-nosis unless they are very early cases. The largest follow-up study is byLjungberg [38], in a highly selected group from the practice of the UniversityHospital in Stockholm. After one year, 43% of men and 35% of women werestill symptomatic. By five years, the figures were 25% and 22%, respectively.On the other hand, acute cases may recover very promptly with limited treat-ment. The sample and selection are immensely important in determining theoutcome, and population studies are infrequent.

Epidemic hysteria has long been known [39]. Outbreaks still occur, evenin developed societies, and many examples have been recognized since theearly nineteenth century. Modern examples were provided by cargo cultsin Melanesia when islanders abandoned their normal activities because of aprophecy that a ship or an aeroplane would arrive laden with many welcomegoods. The ship was expected to be manned by the benevolent spirits ofancestors [40]. Psychological contagion was considered to characterize theseevents. In Western society, Sirois [41] reported two epidemics in schools inQuebec and surveyed altogether 70 reports out of 78 that had appeared inthe world literature from 1872 to 1972.

EPIDEMIOLOGY OF SOMATIZATION DISORDER

Using criteria based on DSM-III, Escobar et al. [42] reported that the lifetimeprevalence of somatization disorder varied between 0.2% and 2% in women,while in men it was likely to be less than 0.2%. Similar data were reportedby Canino et al. [43]. Farley et al. [44] found one case in a sample of 100post-partum women, agreeing with similar findings by Majerus et al. [45]and Murphy et al. [46].


Guze [47], using very strict diagnostic criteria, found somatization disorderin 5–11% of a sample of psychiatric outpatients (according to our interpre-tation of their paper). About 10% of psychiatric inpatients in a universityhospital were reported to be similarly affected [48].

The epidemiology of somatization disorder thus depends greatly upon themode of definition, but most community physicians with, say, 1,000 patientscan expect five or 10 patients satisfying relatively weak criteria to exist intheir practices. Not all of them may be recognized and some physicians mayattract more such patients than others.

The broader term of somatization is applied to many physical symptomsat large when they lack full explanation. In a recent review, Kirmayeret al. [49] summarized knowledge on medically unexplained symptoms andestimated that they comprised 15 to 30% of all primary care consultations.Not all of these should necessarily be regarded as having what has beencalled somatization disorder. Kirmayer pointed out that physicians oftenassume that psychological factors account for these symptoms, but currenttheories of psychogenic causation and somatic amplification could not fullyaccount for common unexplained symptoms. Kirmayer also argued thatpsychological explanations are often not communicated effectively, do notaddress patients’ concerns and may lead patients to reject treatment orreferral because of potential stigma.

Many systems of medicine in different cultures provide social and somaticexplanations linking problems in the family and the community with bodilydistress. Accordingly, most patients could have culturally based explanationsavailable for their symptoms. Once the bodily nature and the culturalmeaning of their suffering is validated, most patients will acknowledgethat stress, social conditions and emotions have an effect on their physicalcondition.

Using a telephone survey in a community sample of 2,400 individuals,Kirmayer et al. [50] reported that 10.5% of respondents had at least oneunexplained symptom in the last 12 months. The most common symptomsreported were similar in both sexes and these corresponded to symptomsfound in other studies of primary care. Musculoskeletal pain affected 30.3%of the respondents; abdominal pain and other gastrointestinal symptomsaffected 17.7%; ear, nose and throat symptoms affected 7.8%; fatigue affected3.9%; and dizziness affected 3.5%.

Their sample included five groups with different ethno-cultural back-ground and migration history: anglophone-Canadian born, francophone-Canadian born, immigrants from the Caribbean, immigrants from Vietnam,and immigrants from the Philippines. There was no difference across cul-tural groups but, when results were stratified by sex, Vietnamese men weresignificantly more likely to report unexplained symptoms than were women(18.3% versus 7.2%). This is in marked contrast to the usual finding that


such symptoms are more common among women, and the authors arguethat this may reflect the high rates of exposure to trauma in this sample,which included many refugees, combined with male reticence in reportingpsychosocial and emotional distress that would help explain the symptoms.

If we compare these cases from no-man’s land with the criteria for soma-tization disorder in DSM-IV, it is noteworthy that the latter system requiresthat each symptom must have been appropriately investigated and cannotfully be explained by a known general medical condition or the direct effectsof a substance and that, where there is a related general medical condition,the physical complaints should be in excess of what would be expected fromthe history of physical examination or laboratory findings.

In the DSM-IV, the residual category exists of ‘‘undifferentiated somato-form disorder’’. Like all residual categories in classification systems thathave to provide for all cases, the criteria are less stringent than for the indexcondition. An extended use of the notion of undifferentiated somatoformdisorder is demonstrated in a paper by DeWaal et al. [51] on somatoform dis-orders in general practice. In this study, the authors arranged a standardizeddiagnostic interview in which they recorded a prevalence of somatoformdisorders of 16.1% among 1,046 consecutive patients of general practitioners.The prevalence increased to 21.9% when comorbid disorders were included,and ‘‘comorbidity of somatoform disorders and anxiety/depressive disor-ders was 3.3 times more likely than expected by chance’’. These results couldonly be achieved by assuming that the ‘‘comorbid somatoform’’ conditionwas to be diagnosed even in the presence of mood or anxiety disorders. Inreaching these figures, the authors sidestepped the hierarchical DSM-IV rulethat undifferentiated somatoform disorders should not be diagnosed in thepresence of another mental illness (including an anxiety disorder or mooddisorder) which would better account for the condition. Even if this rulewere to be observed, their findings would suggest that, after deducting theindividual frequencies of anxiety and depressive disorders, 6.5% of all casesin general practice would still meet their criteria for somatization disorderor undifferentiated somatoform disorder (8.1% if one includes also ‘‘mild’’cases). This study mostly seems to tell us that physical symptoms are com-mon, but does not give us the true proportion of physical symptoms thatmay have to be explained in some purely psychological fashion without thepsychophysiological explanations that could apply in the presence of anxietyor depression.

Overall, broader criteria obviously enlarge the scope of the diagnosis andincrease the frequency or number of diagnoses to be anticipated. They havebeen used by Kirmayer et al. [49] and by Mai [52] to develop informationabout the social and individual factors which influence the presentation ofsomatic symptoms in medical practice. The same may apply to the studyby De Waal et al. [51]. This benefit is achieved at a price, which is the risk

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Somatoform Disorders - download.e-bookshelf.de€¦ · Somatoform Disorders Editors Mario Maj University of Naples, Italy Hagop S. Akiskal University of California, San Diego, USA