HISTORY OF SOMATIZATION DISORDER
Early in my psychiatric career I noticed that some patients who were depressed, responded in a dramatic positive way to antidepressants, while others not only did not respond, they were hypersensitive to the side effects. A significant percentage of non-responders turned out to have somatization disorder. Since this condition is easy to diagnose if the interview is structured properly, many patients can be spared the agonies of unsuccessful medication trials.
Somatization disorder is a disease presenting with multiple emotional and somatic symptoms seen predominately in young females. The condition tends to have a long chronic course, but generally improves somewhat after the age of 40. The patients NEVER fully recover. Somatization disorder was known by other names as long as 4,000 years ago by the Egyptians. They conceived of the disease as caused by a wandering uterus which wandered up to the shoulder and caused shoulder pain, and down to the knee and caused knee pain, and to the back, causing back pain, etc. They thought the uterus was not properly attached in place and put various sweet smelling poultices between the legs to entice the uterus back to the correct position.
The condition was also recognized by the early Greeks who called it “hysteria” the root of the word “hyster” meaning uterus. Undoubtedly, this condition had that explanation because it was seen primarily in females and also because of the frequent gynecological problems that are associated with the condition. In the late 1880’s, Sigmund Freud studied hysteria at a psychiatric hospital known as the Salpetrier. When he was in Paris on a tutorial, Freud saw John Charcot, who was a neurologist, treat a totally paralyzed young lady by hypnosis. Retrospective analysis of that case revealed that she had somatization disorder. At that time, Freud developed the theoretical concept known as conversion hysteria. Freud theorized that the problem was basically emotional, and that the emotional conflicts were converted into physical symptoms — hence the name “conversion hysteria.” This made Freud very enthusiastic about the power of the mind and this led to a whole group of schools of thought with socio-philosophical explanations of the mind and how it created various kinds of mental illness. Freud’s theory was that the ego defense mechanism was in conflict with the id and the superego, and this led to an unconscious conversion of psychic energy into physical symptoms.
The modern concept of hysteria is older than that of Freud, and it began in 1859 in a beautiful monograph in the French literature called the “Triate Clinique et Therapeutique a L’hysterie” by Paul Briquet. In Briquet’s monograph, he carefully and scientifically listed all of the symptoms that the patients had upon examination, for which no medical explanations could be found. His very valuable paper became buried in the literature and received very little attention until it emerged in 1909 when Sevelle, in England, noted it and wrote a few papers on the subject. It resurfaced in 1951 when Dr. Eli Robins wrote what is now a classic paper which was published in the New England Journal of Medicine. In this article, Dr. Robins described somatization disorder and ascribed the name to Briquet. For about thirty years the disorder was referred to as “Briquet’s Syndrome.” This was the first of a series of checklist-type diagnostic procedures which led up to the criteria now listed in the most recent diagnostic and statistical manual published by the American Psychiatric Association. Robins followed a series of patients to make sure the symptoms did not turn into amyotrophic lateral sclerosis or some other biological disorder. He listed these symptoms and came up with a criteria of 23 symptoms that the patients had to have to fit the diagnosis of somatization disorder. Still, this work did not receive wide recognition until Robins became chairman of Washington University and there met a bright young physician by the name of Samuel Guze who then formalized it a bit more using statistical and factorial analysis of the symptoms and correlating medical data came up with a concept that there must be 25 symptoms in 9 categories on a *CHECKLIST* to meet the criteria. This checklist is not only useful in the diagnosis of somatization disorder but in its management. If the patient has one of the symptoms on the checklist it is very likely that the symptom may be attributable to the somatization disorder. However, if there is a symptom that is not on the checklist, such as a sore tooth, then it is likely that the patient has some kind of decay, and the patient should see a dentist.
Somatization disorder differs from hypochondriasis. The predominant disturbance in hypochondriasis is an unrealistic interpretation of physical signs or sensations as abnormal, leading to preoccupation with the fear or belief of having a serious disease. There are no criteria with regard to the number of symptoms that may be present. Hypochondriasis, then, is more of a general descriptive term rather than a recognized and carefully studied disease entity. Now, the checklist is rather long and cumbersome, but as an example, a typical patient will be a female, in her early twenties, complaining of depression, anxiety, colitis, i.e., alternating constipation and diarrhea with fluctuating weight and bloating of the abdomen, and then genitourinary problems, menstrual irregularities, joint pains, panic attacks, shortness of breath, numbness, tingling of the fingertips, gastrointestinal problems, lightheadedness, and is frequently met in the emergency room because of a panic attack precipitated by the patient breaking up with her boyfriend. Frequently, the symptoms are only elicited by direct questioning, and only a few of them, or maybe only one, are brought in as the chief complaint. It is important to inquire about all of these areas.
The symptom combinations are highly variable from one patient to the next. There are some other observations I have made in the 1000 patients I have seen with this disorder that are not on the checklist. There is frequently a “primary male” that plays a big part in the patient’s life – much bigger than normal. This might be a husband or boyfriend, but can even be a father or son. There is enormous dependency on this figure. If the relationship is disrupted, the patient will get much worse and the symptoms will flare up. It is important to ask about this. About 30-40 % of the patients have had a history of rape or incest. They tend to be more outwardly seductive, yet less interested in the actual sex act.
About 30% are hypersensitive to paint fumes, aerosols, insecticides, and vinyl artificial leather, etc. You may have heard of people who are “allergic to 20th century”, and these people have a high correlation with somatization disorder.
As far as epidemiology is concerned, there are twenty females to every one male. The average age of onset is 15 and the condition, generally, becomes full blown by the early twenties and then slowly and gradually improves such that after the age of forty, it has settled down to, perhaps, less than 50% of what it was in the early twenties. It can still flare up after the fifties and sixties, so it is always there, and has a chronic course. The patients frequently have a rather chaotic lifestyle and the illness has a marked impact on functioning so it is difficult to hold a steady job. The disability tends to be due to the personality disorder, rather than the physical symptoms. Approximately twenty percent of first degree female relatives will have somatization disorder. A first degree relative is defined as a relative in the closest proximity, such as a sister, mother, or daughter. If you have a female patient there is a one in five chance that the mother will have somatization disorder, and, there is a one in five chance every sister will have somatization disorder. There is a one in five chance every first degree male relative will develop antisocial personality. People with antisocial personality have a characterologic disorder and tend to have frequent conflicts with authority. They are often involved with drug and alcohol abuse and may exhibit such antisocial behavior as fighting and law breaking. Women with somatization disorder tend to marry one of the three types of individuals: (1) sociopathic–men with antisocial personalities, (2) alcoholic, or (3) a strong paternal fatherly type. They tend to do rather well with the third type and, if they do not marry the third type, will often break up their marriage and will remarry until they find the third type to take care of them.
Treatment involves individual and group counseling as well as hypnosis. Group treatment is useful particularly when it involves the family as well as the patient because experiences can be shared and education can be provided in an effective manner. This is immensely supportive and avoids a great deal of the conflicts which can occur if education is insufficient. Without this vital education, the patient is apt to wander from doctor to doctor looking for someone who knows what they have and knows what to do about it. Frequently this results in enormous amounts of unnecessary money being spent in medical tests and elaborate work-ups, and also unnecessary surgeries, so it is important that the entire medical profession be aware of this condition and its diagnosis and treatment in making the decision of whether or not to operate or proceed with other medical measures. This is not to say that patients should not be operated on at all, of course. It is just that the whole picture needs to be taken into consideration.
Sometimes there is a tendency to take more medication than is prescribed. This is not true with everyone, but there is a small percentage of somatization disorder patients that are in so much pain that they crave medications and will, in moments of desperation, take handfuls of additional medication, either in an attempt to commit suicide or, much more frequently, to simply snow themselves under and leave the world for awhile. For this reason, it is essential, in selected cases, that the medicine be dispensed by another party, usually a family member. the medicine, in these cases, should be kept in a locked box under very tight security. A patient in severe distress, whether it be emotional or physical, is likely to use poor judgment in monitoring his medication and, typically, most patients take several overdoses during their life, and although most of them tend to be sub-lethal, there are occasional deaths which can be prevented by proper management. This is another reason why it is important to involve the family in the treatment and also in the educational groups – to reinforce, over and over again, the importance of proper regulation of medicine, tight security, and close communications with the specialist doctor who is managing the case.
While the primary management of the somatization disorder itself should be by a psychiatrist, the patient should not lose contact with other physicians, particularly internist or family practitioner and gynecologist. The physicians should work together as a team providing care for the whole patient. it is particularly important that all the doctors involved in the case know what other doctors are prescribing. Almost all of the patients are hypersensitive to non-narcotic medication and cannot tolerate many antidepressants. They may want to be on no medications at all, or on low doses of a benzodiazepine. A small percentage of patients claim they have a very high drug tolerance, and try to persuade the doctor to prescribe sedatives or stimulants or both in doses higher than the doctor is comfortable with. Hypnosis is a very useful adjunct in the treatment of somatization disorder.
It is likely that in the historical development of this disorder that many FMS (fibromyalgia) patients were included in the SD population. There is also some overlap in symptoms such as hypersensitivity to drugs, fumes, sounds and other environmental stimuli. The Chinese do not distinguish between physical and emotional illness. Perhaps we have something to learn from them.