Trauma-related psychiatric comorbidity of somatization disorder among women in eastern Turkey
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 In DSM-5, SD has been replaced by somatic symptom disorder [8].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)
Somatization: medicine's unsolved problem
Psychosomatics
(1987)- et al.
The prevalence of conversion symptoms in women from a general Turkish population
Psychosomatics
(2009) - et al.
Somatic symptom disorder: an important change in DSM
J Psychosom Res
(2013) - et al.
Somatic symptoms in multiple personality disorder
Psychosomatics
(1989) - et al.
Prevalence of dissociative disorders among women in the general population
Psychiatry Res
(2007) - et al.
Post-traumatic stress disorder and somatization symptoms: a prospective study
Psychiatry Res
(1998) - et al.
PTSD and somatization in women treated at a VA primary care clinic
Psychosomatics
(2004) The scope of dissociative disorders: an international perspective
Psychiatr Clin North Am
(2006)- et al.
Dissociative experiences and psychopathology in conversion disorders
J Psychosom Res
(1999) - et al.
Lifetime posttraumatic stress disorder and quality of life among alcohol dependent men: impact of childhood emotional abuse and dissociation
Psychiatry Res
(2011)