Elsevier

Comprehensive Psychiatry

Volume 55, Issue 8, November 2014, Pages 1837-1846
Comprehensive Psychiatry

Trauma-related psychiatric comorbidity of somatization disorder among women in eastern Turkey

https://doi.org/10.1016/j.comppsych.2014.08.052Get rights and content

Abstract

Objective

This study sought to determine the trauma-related psychiatric comorbidity of somatization disorder among women who applied to an outpatient psychiatric unit of a general hospital in eastern Turkey.

Methods

Forty women with somatization disorder and 40 non-clinical controls recruited from the same geographic region participated in the study. Somatization disorder and posttraumatic stress disorder (PTSD) sections of the Structured Clinical Interview for DSM-IV (including its criterion A traumatic events checklist), Dissociative Disorders Interview Schedule, Dissociative Experiences Scale (Taxon), Hamilton Depression Rating Scale, and Childhood Abuse and Neglect Questionnaire were administered to all participants.

Results

A significant proportion of the women with somatization disorder had the concurrent diagnoses of major depression, PTSD, dissociative disorder, and borderline personality disorder. Women with somatization disorder reported traumatic experiences of childhood and/or adulthood more frequently than the comparison group. A significant proportion of these patients reported possession and/or paranormal experiences. Binary logistic regression analysis demonstrated that current major depression, being married, total number of traumatic events in adulthood, and reports of possession and/or paranormal experiences were independent risk factors for somatization disorder diagnosis.

Conclusions

Among women with endemically high exposition to traumatic stress, multiple somatic complaints were in a significant relationship with major depressive disorder and lifelong cumulative traumatization. While accompanying experiences of possession and paranormal phenomena may lead to seeking help by paramedical healers, the challenge of differential diagnosis may also limit effective service to this group of somatizing women with traumatic antecedents and related psychiatric comorbidities.

Introduction

The term somatization refers to the tendency of experiencing and communicating psychological distress in the form of somatic symptoms with no pathological explanation [1]. The prevalence of medically unexplained symptoms is high in many cultures [2], including Turkey [3]. Somatizing patients have disproportionately elevated rates of health care utilization and contribute to increasing cost of health care service [4]. As those patients are usually dissatisfied with their medical care and tend to consult multiple physicians for the same problem, physicians find them as challenging [5].

Somatization disorder (SD) is the most extreme form of somatization and is defined as a history of at least eight medically unexplained symptoms affecting multiple functional systems [6]. The symptoms usually begin before the age of 30 and are associated with high level of psychological distress, functional disability and excessive medical help-seeking behavior [7]. In DSM-5, SD has been replaced by somatic symptom disorder [8]. In this new formulation, the emphasis has shifted from the number of medically unexplained symptoms to the impact of those symptoms on an individual's thoughts, feelings and behavior. According to the diagnostic criteria of somatic symptom disorder, one or more somatic symptoms that are distressing or result in significant disruption of daily life must be accompanied by disproportionate or excessive thoughts, feelings or behaviors. Although members of the DSM-5 workgroup for somatic symptom disorders insist that this change encourages comprehensive assessment of patients for accurate diagnoses and holistic care [9], some authors, on the other hand, have stated their concerns as these new criteria's may be problematic in terms of misdiagnosis [10].

SD commonly coexists with other psychiatric disorders including depressive [11], [12], dissociative [13], [14], [15], conversion [16], [17], borderline personality [18], and post-traumatic stress disorders (PTSD) [19], [20], [21]. Constituting the most extreme form of medically unexplained symptoms, several studies pointed to the relationship of SD to traumatic experiences of childhood and adulthood [21], [22], [23], [24], [25], [26]. There are also claims that SD is closely associated with dissociation and PTSD [20], [21], [23], [25], [26], [27], [28], [29], [30].

Patients with SD endorse more psychiatric symptoms than do most of the patients with other psychiatric disorders. Consequently, SD may mimic other psychiatric disorders [31]. On the other hand, exposure to multiple traumatic events result in a greater number and variety of symptoms that include not only depressive, PTSD and/or somatic symptoms, but also others reflecting affect dysregulation, loss of impulse control, dissociation, and disturbances of self [32], [33], [34]. The symptom complexity in such patients is closely related to cumulative trauma [33], [34], [35].

The present study tried to inquire the trauma-related clinical correlates of SD such as major depression, PTSD, dissociative disorders, and borderline personality disorder in a group of women who are exposed to diverse types of traumatic stress endemically. Residing in the least industrialized district of Turkey, this group of women with limited education originated from a low socioeconomic level. We compared these patients with a matched non-clinical control group recruited from the same region.

Section snippets

Participants and procedure

This study was conducted in Mus-City, a small town located in eastern Turkey with a population density below the average of the country. According to the government reports, it is economically the least developed district of Turkey [36]. Although there are settlements with more than 10,000 people in the area, Mus-City is considered to be a conglomerate of settlements typically representing rural and semi-rural areas of eastern Turkey. Subjects were recruited from psychiatric outpatient unit of

Sociodemographic characteristics

The final sample consisted of 40 women with SD and 40 non-clinical controls. There was no significant difference between SD (32.5 ± 9.3) and control (32.2 ± 6.4) groups on age (U = 726.00, p = 0.476). Average education (in years) of SD patients (3.6 ± 3.8) and controls (3.0 ± 3.7) did not differ either (U = 734.00, p = 0.494).

Women in the SD group were more likely to be married than women in the control group (χ2 = 4.82, df = 1, p = 0.028). Mean age of entering marriage was significantly lower in the SD group (16.6 ± 

Discussion

In the present study, women with SD had elevated numbers of trauma-related psychiatric comorbidities including depressive, post-traumatic stress, dissociative, and borderline personality disorders. Moreover, SD group had significantly high frequencies of traumatic experiences in childhood and/or adulthood. Overall, this study confirms the relationship between traumatic stress and functional somatic complaints [23], [24], [25], [26], [35], [51], [52].

The close relationships between somatization,

Conclusions

Symptom complexity emerging after cumulative trauma has been shown in numerous studies and our data support this notion [33], [34], [35]. The present study suggests that women with SD are more likely to suffer from trauma-related psychiatric comorbidities; i.e. from depressive disorder in particular. While these findings are valid for this group of women who apply to a general hospital, accompanying experiences of possession and paranormal phenomena may lead to seeking help by paramedical

References (64)

  • L.J. Kirmayer et al.

    Culture and somatization: clinical, epidemiological, and ethnographic perspectives

    Psychosom Med

    (1998)
  • A. Landa et al.

    Beyond the unexplainable pain: relational world of patients with somatization syndromes

    J Nerv Ment Dis

    (2012)
  • A.J. Barsky et al.

    Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity

    Arch Gen Psychiatry

    (2005)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1994)
  • L.J. Kirmayer et al.

    Abnormal illness behaviour: physiological, psychological and social dimensions of coping with distress

    Curr Opin Psychiatry

    (2006)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2013)
  • A. Frances

    The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill

    BMJ

    (2013)
  • G.E. Simon et al.

    Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study

    Am J Psychiatry

    (1991)
  • C. DeSouza et al.

    Major depression and somatization disorder: the overlooked differential diagnosis

    Psychiatr Ann

    (1988)
  • G. Saxe et al.

    Somatization in patients with dissociative disorders

    Am J Psychiatry

    (1994)
  • V. Sar et al.

    Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder

    Am J Psychiatry

    (2004)
  • E.S. Bowman et al.

    Psychodynamics and psychiatric diagnoses of pseudoseizure subjects

    Am J Psychiatry

    (1996)
  • J.J. Hudziak et al.

    Clinical study of the relation of borderline personality disorder to Briquet’s syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders

    Am J Psychiatry

    (1996)
  • A. Elklit et al.

    Predictive factors for somatization in a trauma sample

    Clin Pract Epidemiol Ment Health

    (2009)
  • E.F. Pribor et al.

    Briquet’s syndrome, dissociation, and abuse

    Am J Psychiatry

    (1993)
  • J. Morrison

    Childhood sexual histories of women with somatization disorder

    Am J Psychiatry

    (1989)
  • C. Spitzer et al.

    Childhood maltreatment in patients with somatization disorder

    Aust N Z J Psychiatry

    (2008)
  • R.J. Brown et al.

    Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder

    Am J Psychiatry

    (2005)
  • V. Sar

    Medically unexplained symptoms in women

  • J.I. Escobar et al.

    Somatic symptoms after a natural disaster: a prospective study

    Am J Psychiatry

    (1992)
  • M. Aragona et al.

    The relationship between somatization and posttraumatic symptoms among immigrants receiving primary care services

    J Trauma Stress

    (2010)
  • H. Glaesmer et al.

    Posttraumatic stress disorder and its comorbidity with depression and somatisation in the elderly—a German community-based study

    Aging Ment Health

    (2012)
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