Jmmal of Psychosomam Research. Vol. 36, No. 2. pp. 125-136, Printed m Great Bntain.
PHYSICAL
COMPLAINTS
1992. 0
AND SYMPTOMS
LXX-3999/92 $5.00+ 00 1992 Pergamon Press plc
OF SOMATIZING
PATIENTS PER FINK (Received
22 January 1991;
accepted
in
revised
form
26 June
1991)
Abstract-The purpose of the study was to describe the physical complaints and symptoms of persistent somatization patients. Individuals in the general population (age 17-49 yr) with at least 10 general admissions during an S-yr period were studied. Persistent somatizers (i.e. patients with more than six medically unexplained general admissions) were compared with patients whose admissions could be ascribed to well-defined somatic disorders. Somatizers were characterized by multiple symptoms from many organ systems, and their physical complaints simulated most types of somatic disorder. Although some symptoms were more common than others, none were infrequent, so neither ‘classic’ conversion symptoms nor pain symptoms were found to be especially characteristic of the persistent somatizer. Gender had no influence on number of registered symptoms, whereas the number increases with age. The finding question the use of a predefined symptom checklist in the diagnostic criteria for somatizing disorder. The major part of the somatizers present a different illness picture when admitted with medically unexplained disorders compared with admission for which no adequate medical explanation could be found. However, one fifth had, when admitted with a medically explained diagnosis, also been admitted with the diagnosis medically unexplained at another admission. One fifth of the persistent somatizers had been admitted at least once for factitious illness, but apart from the fact that they had more symptoms and admissions, they did not differ from the other persistent somatizers.
INTRODUCTION
complaining of physical illness or symptoms that cannot be explained by a detectable somatic disease or pathophysiologic mechanism have been described under many different labels such as Munchausen’s syndrome [ 11, hysteria, crocks [ 21, peregrinating problem patients [ 3 ] , hospital addiction [ 41. In DSM-III-R they are mainly categorized under one of the somatoform disorders, chronic factitious disorder or somatic delusions [5] . In this report the term somatization patients will be used according to the definition given by Lipowski [6 ] . There is some confusion and disagreement on the diagnostic criteria for the different syndromes and there has been a high degree of overlapping. The type and the character of the somatic symptoms (e.g. pain, conversion symptoms), and the way they are presented and produced by the patient (e.g. self-induced/inflicted, unconscious/conscious) plays a major role in diagnosing and in distinguishing between the syndromes [6-81. The diagnostic categories or syndromes are mainly developed on the basis of observation done among patients attending to psychiatric setting or on the basis of case reports. Because somatizing patients present primarily to non-psychiatric physicians and may refuse psychiatric referral, a non-psychiatric setting would be a more ideal setting for the study of somatization illness. Recently a study was carried out on 282 individuals with a heavy utilization of general in-patient admissions (10 or more during an 8-yr period). Approximately PATIENTS
Institute
of Psychiatric
Demography,
Aarhus
Psychiatric 12.5
Hospital,
DK-8240
Risskov,
Denmark
126
PER FINK
20% of these patients had no physical disorder that could adequately explain their multiple admissions [ 91 . The aim of this report is to describe the physical symptoms and illness complaints that had brought these patients to hospital. The sociodemographic characteristics as well as age at onset and utilization of admissions of these patients have been described elsewhere [9] METHOD The population basis consists of all 17-49 yr olds living in two Danish municipalities (15.609 men and 14,818 women, age on 1 January 1984). The hospitalizations of the population cohort were followed during the period 1977-1984 by means of The National Patient Register. This is a nationwide patient register where all in-patient admissions to non-psychiatric departments in Denmark smce 1977 are registered [lo] The data are person identifiable by the CPR number (central person registration number) which is a number all Danes get at birth. The results on the patient register investigation have been reported elsewhere 19, 1l-131. In the present study are included the approximately 1% (N = 282) of the general population with IO or more general admissions during the S-yr period. Since the topic for this investigation was somatization, patients whose course of illness could be ascribed to a somatic disease with a high diagnostic reliability or well-established treatment routines were excluded on the basis of discharge diagnosis in the National Patient Register. Diseases which led to exclusion (number of patients in parentheses) were*: diabetes mellitus (41), colitis ulcerosa (5), malignant tumours (27), uraemia (9), haemophilia (2), desensitization treatment (6), fractures (45). various other well-defined diseases (7). Moreover one patient treated for manic-depressive psychosis at a non psychiatric department was excluded. One more patient was excluded because access to her medical record was refused by the department. Thus, the study population consisted of 138 patients, whose medical records were reviewed covering all admissions to general hospital from birth to 31 December 1984. Admissions previous to the establishment of the National Patient Register in 1977 were traced through information about ‘previous illness’ which is a standard item in Danish medical records. Admissions to out-patient units were not registered if they led to hospitalization or were part of an aftercare or checkup. The 138 patients had in total 2930 genera! in-patient and 93 out-patient admissions from birth to 1985 (excluding admissions due to pregnancy, abortions and sterilizations). Based upon a data extraction from the medical records it was registered for each crdmissiun whether it: (a) Was caused by physical symptoms/complaints that could not be explained adequately by any detectable somatic disorder (i.e. medically unexplained) (N = I, 126). In this report ‘no adequate medical explanation’ means that the complaints were considered to be grossly in excess of what one would expect on the grounds of objective medical findings (e.g. ‘3 years after the relatively moderate trauma of the knee joint, the patient still has subjective complaints which do not correspond to the objective findings, a slight atrophy of the quadriceps’). If it was unclear (which was the case in 8% of the admissions) whether an admission was adequately explained by somatic disease or not. it was placed in category (a). Self--inflicted lesions/diseases where the self-infliction was denied by the patient (factitious disease) fell in category (a). (b) Was caused by a somatic verifiable disease (i.e. medically explained) (N = 1,321). (c) Was a straightforward psychiatric case (N = 576). Admissions due to self-destructive acts (suicidal attempt, self-mutilation), alcoholism and drug dependence or complications to these (cirrhosis hepatitis, chronic pancreatitis) were placed in this category. In these cases both the patient and the physicians were fully aware of the psychiatric caseness wherefore the question: somatization or genuine somatic disorder. was irrelevant. The medical records from the general hospital primarily serving the patients resident in the area were first reviewed. If it could be certified on this basis that the admissions were not due to somatization, only discharge letters of admission to other hospitals were obtained and no symptoms were registered. However, if information in the discharge letters raised the question whether the admissions were adequately explained by a somatic disease or was due to straightforward psychiatric admissions, the complete medical records were obtained and symptoms were registered. For each admission a diagnosis representing the pattern of illness of a somatic disorder causing the admission was registered (admission diagnosis). In cases of a verifiable somatic disease the department discharge diagnosis was used. If the admissions were caused by a complication to a chronic disease the
*Details
concerning
the operationalizing
criteria
can be requested
from the author
Physical
complaints
of somatizing
patients
127
diagnosis of this was used. If no verifiable physical disease was detected the tentative diagnosis of the department was used, or in cases where the tentative diagnosis was undescriptive (e.g. observation), the admission diagnosis given by referring physician was used. The complaints were registered on a list of 67 predefined symptoms plus 6 ‘other’ symptoms distributed according to organ system. * Only symptoms which either the physician or the patient attributed to the physical illness that had caused the admission were registered. After the review of the medical records it was clear that a group of the patients were straightforward psychiatric cases, i.e. the main part of their admissions were due to substance abuse, suicidal attempt etc. (category c admissions). Since the topic for this report was somatization, patients with less than 10 admissions due to physical symptoms or complaints were excluded. Twenty-five patients were excluded by this criterion and they had all at least six straightforward psychiatric admissions (category c admissions) and no more than four admissions due to medically unexplained physical complaints. The remaining 113 patients had at median six medically unexplained admissions in a lifetime. Patients were grouped as persistent somatizers (som) (N = 56) if they had more than six admissions due to medically unexplained physical complaints or symptoms and as non-somatizers (N = 57) if six or less. For a more detailed discussion on the grouping of the patients see elsewhere [9] Nine of the persistent somatizers were males. 47 females against 24 and 33, respectively, of the non-somatizers 0, < 0.01). The median age of the persistent somatizers was 35.8 yr against the non-somatizers 40.8 yr. The difference was not statistically significant controlling for gender 0, > 0.05). Seventy per cent (1,016) of the persistent somatizers’ admissions were medically unexplained, 163 (1 1%) due to straightforward psychiatric admissions against 86 (8%) and 50 (5 %) respectively, of the non-somatizers. In this report conversion symptoms only means ‘classic’ conversion symptoms, i.e. medically unexplained symptoms suggesting a neurologic disease [ 141. Factitious illness in this report only includes disorders resulting from self-inflicted illness where the self-infliction is denied by the patient and illness suspected on the basis of the patient’s manipulation with objective symptoms (for definition of objective symptoms see Ref. [ 151). No attempt was made to distinguish between unconsciously or intentionally produced symptoms. Statistics The data were processed by means of the BMDP Statistical Software [ 161 Multiway interactions between variables were investigated by means of hierarchical log linear analysis of contingency tables with stepwise backward elimination of interactions using the 4F programme in BMDP. Two-way interactions using the 4F programme in BMDP. Two-way interactions between variables were depending on the distribution tested by chi-square test, Fisher’s exact test (two-tailed), or Mann-Whitney U-test. Ninety-five per cent confidence limit was used.
RESULTS
Admission
diagnoses
In Table I the admission diagnoses are divided into 38 categories distributed according to organ system. The percentage of the persistent somatizers admitted at least once with the diagnosis and the percentage of the persistent somatizers’ total number of admissions where the diagnosis was used is shown for each diagnostic category. Gastrointestinal diagnoses were the most common admission diagnoses as 96% of the persistent somatizers had been admitted at least once with this diagnosis. More than 90% had been admitted at least once with the diagnosis medically unexplained. In total these diagnoses account for more than VI of the persistent somatizers’ admissions. Compared with the non-somatizers the persistent somatizers had a 24 times higher risk (i.e. OR = 24) of having been admitted with a gastrointestinal diagnosis, either medically explained or unexplained. It is seen that unspecific abdominal pain accounts for 14% of the persistent somatizers’ admissions and 3/4of the patients had
*Complete
list of symptoms
can be requested
from the author
PER FINK
128 TABLE
I.-ADMISSION
(OR .r”wrArtv”
DIAGNOSES) OF THE PEastsrnNT
Percentage of patients at least once admitted diagnosis
(N = 56) with the
S~MAT~ZAT~ON
PATIENTS
Percentage of admissions (N = 1,473) with the admission diagnosis ___Medically I” Som vs unexplained total? nsom % % OK1
Medically unexplained E
I” total? %
Som vs “som GKi
91.1
96.4
24.4***
25.7
28.7
4.6***
76.8 25.0 23.2
76.8 33.9 25.0
15.6*** 3.7** 2.0
13.8 1.2 4. I
13.8 1.6 4.4
14.1*** 2.1 3.2***
19.6
30.4
1.8
2.7
4.2
17.9 12.5 8.9
17.9 12.5 19.6
6.0** 8.0* 1.7
I .4 1.1 1.4
1.6 1.1 2.0
diseases!
87.2
93.6
5.5**
13.4
16.1
Menstrual irregularity Salpingo-oophoritis acuta Other gynaecological diseases Extrauterine pregnancy Mamma tumor”, hypertrophia, infections
70.2 21.3
74.5 23.4
3..5** 2.2
9.2 1.4
9.5 I .5
1.8** 0.8
19.1 17.0
38.3 19.1
0.7 3.7
0.9 1.1
2.4 1.4
0.3*** 3.7
8.5
17.0
1.1
0.8
1.4
1.1
Admission
diagnoses
I Gastrointestinal
diseases
Abdominal pain Appendicitis Gastrointestinal ulcer Other GI diseases (including liver, gall, pancreas) Diarrhoea, anorexia, malabsorption Cholelithiasis/cholecystitis Anal diseases II Gynaecological
III CNS diseases Epilepsy, convulsions CNS traumas Headache Other CNS diseases Fainting Neuritis/neuralgia, nerve-root compression Multiple sclerosis IV Musculo-skeletal
diseases
Back pain (incl. disc) Other traumas Knee diseases Other musculo-skeletal diseases V Urinary
system
diseases
Pylero-nephritis, cystitis urolithiasis Urine incontinence/urine retention, other urinary diseases Kidney/urinary system, venereal diseases VI Endocrine, febrilia, metabolic diseases
-
1.2 8.8*** I I .6*” 2.1* 1.1
71.4
80.4
5.2***
9.8
13.4
0.6***
26.8 25.0 21.4 21.4 19.6
26.8 37.5 23.2 21.4 19.6
3.1* 3.2** 5.4** 1.3 3.2*
2.0 1.5 1 .o 1.2 1.6
2.6 3.2 1.1 2.2 1.6
0.7 0.8 3.9* 0.3*** 4.4**
14.3 7.1
17.9 7.1
3.9* 2.1
1.1 1.5
1.2 1.5
0.8 0.8
62.5
78.6
1.6
9.8
13.2
0.4***
26.8 26.8 19.6
26.8 44.6 23.2
0.5 I .6 I .9
4.9 1.8 2.3
5.3 3.6 3.0
0.3*** 0.4*** 2.0*
12.5
17.9
0.9
0.9
1.3
0.2***
41.1
42.9
I.8
6.2
6.8
0.8
32.1
32.1
4.0**
4.3
4.6
1.5
16.1
16.1
-**q
1.7
1.8
_***q
7.1
10.7
0.4
0.3
0.4
0.1***
19.6
25.0
2.4
1.4
1.7
1.5 (Continued).
Physical
TABLE
complaints
of somatizing
patients
129
I.-CONTINUED
Percentage of patients at least once admitted diagnosis
Admission
Medically unexplained %
diagnoses
VII Skin diseases Skin diseases Abscesses/lymphangitis VIII Cardiac
diseases
Cardiac ischaemic disease Other cardiac diseases IX Eye/ear/nose, diseases X Pulmonary
In totalt %
(N = 56) with the Som vs nsom OR$
Percentage of admissions (N = 1,473) with the admission diagnosis Medically unexplained %
In totalt %
Som vs nsom ORI:
14.3
25.0
1.4
1.4
2.9
0.8
8.9 5.4
21.4 8.9
1.7 1.8
0.7 0.7
2.0 0.9
0.6* 3.1
10.7
10.7
I .2
1.1
1.2
8.9 1.8
8.9 5.4
5.5 0.6
1.0 0.1
1.0 0.2
10.9*** 0.1***
10.7
19.6
3.2”
0.5
1.1
0.6***
7.1
16.1
0.5
1.5
5.9
0.5***
5.4 3.6
12.5 5.4
0.4 0.8
0.3 1.2
1.o 4.9
5.4*** 0.9
I
10.7
2.2
0.4
0.7
0.2***
0.6
throat
diseases
Other pulmonary Asthma
diseases
XI Blood diseases,
phlebitis
7.
attempts
-
50.0
3.4**
11.1
3.4***
-
46.4 8.9 7.1
3.6”* 1.0 2.1
10.3 0.5 0.3
4.7*** 0.2*** 0.9
XII Abuse,
suicidal
Poisoning Alcoholism Drug dependence
-
*p < 0.05, **p < 0.01) ***p < 0.001. iEither medically explained or unexplained. *Odds ratio for the persistent somatizer of having been admitted with the diagnoses compared to the non-somatizer. SPercentage of females only. (None of the non-somatizers had been admitted under the diagnosis and therefore no odds ratio was calculated. been admitted with this diagnosis at least once. Among the females almost as great a percentage has been admitted due to symptoms suggesting a gynaecological disorder. But in contrast to the gastrointestinal diseases it is seen that these diagnoses do not account for a greater number of the persistent somatizers’ admissions than of the non-somatizers’ (OR = 1.1) despite the fact that significantly more of the persistent somatizers had been admitted with the diagnosis (OR = 5.5). Central nervous system diagnoses were the third most common admission diagnoses, but except for headache and fainting the CNS diagnoses account for a greater number of the nonsomatizers’ admissions than of the persistent somatizers. Further it is seen that half of the persistent somatizers had been admitted at least once because of poisoning, alcoholism or drug dependence. In general Table I shows that the group of persistent somatizers had their admissions attributed to a wide range of diagnoses and none of the diagnoses were uncommon. At median eadl persistent somatizer had during admissions been diagnosed with 8 (Ql-Q3: 6-11 max. 21) different diagnostic categories either medically
PER FINK
130
explained or unexplained which was significantly more than the non-somatizer (median 5, Ql-Q3: 3-6 max. 10) @ < 0.000). Looking at the 12 organ system categories only, the somatizer had been hospitalized for diagnoses belonging to median 5 (Ql-Q3: 4-6 max. 10) organ systems and the non-somatizer median 3 (Ql-Q3: 2-4.5, max. 6) CJI< 0.000). Gender and number of admissions had no influence on the number of diagnoses whereas there was a small, but statistically significant increase in the number of different diagnoses by age among the group of persistent somatizers, but not among the non-somatizers. Figure 1 shows that each persistent somatizer’s most frequently occurring diagnostic category at median accounts for 33 % of the admissions, the two most frequent diagnostic categories for 55 % etc. It is seen that the admissions of the non-somatizers were explained by diagnoses belonging to significantly fewer diagnostic categories (Mann-Whitney U test separately for each number of diagnoses, all p < 0.000). No significant sex or age differences were found in this aspect.
I
I 1
O
I
I
I
I
I
I
I
2
3
4
5
6
7
6
Priority of diagnoses
0 FIG. 1. Cumulative
Persist. somatizer
I
x Non-somatizer
QlU3
percentage nf each patient’s admkions
(median)
explained
by number of diagnoses.
Do the persistent somatizers present the same illness picture on their medically explained and their medically unexplained admissions? Leaving out admissions due to substance abuse and suicidal attempt, the persistent somatizers at median had been admitted with six (Ql-Q3: 5-S) different medically unexplained diagnoses, two (QlQ3: l-3) different medically explained diagnoses and one (Ql-Q3: O-l) diagnosis which had been both medically explained and unexplained (i.e. on one admission medically explained, but on another medically unexplained). Only nine (16 o/o, including four of the nine males) had been admitted with more than one diagnosis both medically explained and unexplained. However, 12 (21%) all females) of the persistent somatizers who had been admitted with a medically explained disorder had also been admitted on another occasion with the same diagnosis medically unexplained. Symptoms
In Figure 2 the persistent somatizers’ primary symptom complaints are shown for admissions other than those with a diagnosis of substance abuse or poisoning.
Physical complaints of somatizing patients percentage patients
131 percentage
Of (n-56j2
admissions
Cl
(n-1271J3
r
CNS Anaesthesia Vision disturbances Syn kope paresis Urinary retention Convulsions Amnesia Ataxla Other symptoms Tremor Unconsciousness Confusion Aphasia PAIN Gastrcintestlnal Extremities Headache Cardiopulmonal UrOgenltaI GASTROINTESTINAL Upper abdomen Diarrhea Other (-paIns) Obatipatlcn Borborhygmla Melaena Haematemesi8 UNSPECEFIC Fstlgue Fainting Few L0e.a of weight UROGENITAL symptoms+ Dlsoh.rge4 Dysuria4 Dyspareunla Other symptoms urine Incontfnence
r
Menstrual
4
SKIN - EXTREMITIES Wounds-suggllatlon Function dlfflculty Other aymptomn CARDIOPULMONARY Dyspnoea Other symptoms Cough OTHER
ORGAN
SYSTEMS 100%
60%
60%
40% Medical.
20%
0%
unexplained
20% Kiln
40% total
Complaints which the physician or the patient attributes to the illness as causina the admission. Admissions due to substance abuse, poisoning and pregnancy are excluded Percentage of the persistent somatizers who had the complaint on at least one admission Percentaqe of the persistent somatizers' admissions where the symptoms are registered Percentage of females only FIG.2. Primarysymptom complaints of thepersistent somatizers.
Apart from convulsions, tremor, unconsciousness, CNS symptoms, cardiopulmonary and ‘other’ urogenital
confusion, symptoms,
aphasia, ‘other’ all the symptoms
132
PER FINK
were registered at least once among significantly (p < 0.05 Mann-Whitney test) more of the persistent somatizers than among the non-somatizers (either medically explained or unexplained). Only vision disturbances, gastrointestinal pain, upper gastrointestinal symptoms (i.e. nausea, vomiting, pyrosis), ‘other’ GI symptoms, dizziness and dysuria were seen at a significantly greater number of the persistent somatizers’ admissions. On the other hand, several of the other symptoms (Fig. 2) were registered at a significantly greater number of the non-somatizers’ admissions. Eighty-nine per cent of the persistent somatizers had on at least one medically unexplained admission a complaint of one of the ‘classic’ conversion symptoms (i.e. the symptoms listed under ‘CNS’ excluding ‘other’) and one of these symptoms was registered at 115of the group of persistent somatizers’ admissions. The most frequent symptom registered was gastrointestinal pain which was registered at 49% of the group of persistent somatizers’ admissions. The persistent somatizers had throughout their admissions at median 22.5 (QlQ3: 19-29, max. 40) different symptoms (out of 73 possible) against the nonsomatizers’ 11 (Ql-Q3: 6.5-14.5, max. 26). The number of registered symptoms correlated to a certain degree to number of admissions, but the difference was significant even when comparing patients from the two groups corrected for number of admissions @ = 0.007). The number of registered symptoms was not related to gender whereas the number of symptoms increases significantly with age among the persistent somatizers, but not among the non-somatizers. Factitious
illrws
Intentionally self-inflicted diseases or lesions simulating a disease were discovered in five of the persistent somatizers (three females, two males). One patient had a selfinduced anal dermatitis and one had by scratching induced lesions simulating a universal dermatitis. Further one patient had been admitted with a universal dermatitis which was caused by abuse of diuretica. Two patients had created multiple abscesses with a needle. One of these patients further simulated an arthritis by selftraumatizing and simulated a fever. Nine of the persistent somatizers (including four of the five above-mentioned patients) (two males, seven females) were discovered on at least one admission to have manipulated with objective symptoms or signs. One patient had induced haematuria, one patient simulated haematemesis several times by eating elderberry syrup, and nine patients had on at least one admission simulated In total ten (18%) of the persistent fever by manipulation of the thermometer. somatizers had thus been admitted at least once to factitious illness, in four patients, however. only discovered at one admission. Further, one of the non-somatizers was found to have simulated a fever at one admission. The patients admitted due to factitious illness did not differ from the other persistent somatizers as to age and gender, but had more admissions (p < 0.05) and a nonsignificant tendency towards more different diagnoses and symptoms. DISCUSSION
Persistent somatizers were in this report defined as patients with more than six general admissions for medically unexplained physical symptoms. The patients were selected from a general population and they were followed in their lifetime before
Physical complaints of somatizing patients
133
1985, covering all admissions to all types of non-psychiatric departments. In this respect this report differs methodologically from all other studies which deal mainly with patients referred to or attending a psychiatric service [ 17-201 . The physical complaints of the patients were described using either diagnostic labels and/or symptoms. Such an approach has advantages as well as disadvantages. A diagnostic label transmits a rapid understanding of the way the physician sees the problem which is presented to him and contains more information than a simple list of symptoms [ 1.51. On the other hand, the tentative diagnosis will depend on the viewpoint and the skills of the physician (i.e. a gynaecological specialist will think of a gynaecological disorder as a first choice) whereas symptoms will give a more objective description. Since this investigation is based on record material the number of symptoms probably tends to be underestimated as the patients were not asked about all possible symptoms, and statements like ‘the patient complains of numerous symptoms from many organ systems’ were not infrequently seen in the records. On the other hand Martin et al. [ 2 1 ] found that independent medical records often revealed much more unexplained complaints than were reported by the patients at the diagnostic interview for Briquet’s syndrome. Looking at the persistent somatizers as a group, the data show that although some symptoms were more common than others, none were infrequent and that the physical complaints of the persistent somatization patients may mimic almost any somatic disorder. Also on an individual basis the persistent somatizers were characterized by having multiple complaints from many organ systems whether counting each patient’s number of symptoms or number of received diagnostic labels. Dividing somatization syndromes into different subtypes on the basis of the physical complaints (i.e. neurologic, haemorrhagic, abdominal etc.) [22-251 thus seems to be a useless task, as the patient on one admission will belong to one subtype, but on another to a different subtype. ‘Classic’ conversion symptoms (i.e. medically unexplained symptoms suggesting a neurological disorder [5, 141 has traditionally had a dominating role in the diagnosis of hysteria [26] The present study does not support the theory that ‘classic’ conversion symptoms could be more characteristic of hysteria (or somatization) than of other medically unexplained symptoms, since the latter were just as frequent, or even more frequent, among the persistent somatizers than the ‘classic’ conversion symptoms. Furthermore, none of the persistent somatizers were of monosymptomatic ‘conversion types’. Since other reports have not demonstrated any correlation between the occurrence of conversion symptoms and correlation between the occurrence of conversion symptoms and hysteria or a hysterical personality [ 26-3 1 ] the theory of a correlation may be ascribed to the lack of representative empirical data on the subject. The term hysteria has now been eliminated as obsolete [ 61 and replaced by other diagnostic categories in DSM-III-R, mainly somatization disorder. The diagnostic criteria for this disorder are that the patients must have at least 13 medically unexplained physical symptoms out of a list of 35 predefined symptoms [5]. The criteria are a modification of the criteria previously established by Perley and Guze [ 201 to define Briquet’s disorder [ 321. Perley and Guze based their work on observations done by Briquet, Pm-tell et al. and Robins and O’Neal [ 201, who registered
134
PER FINK
the symptom complaints among patients who were referred to psychiatric services and were given a diagnosis of hysteria. The present report on patients attending nonpsychiatric hospitals shows that although the 35 predefined DSM-III-R symptoms were frequent among the persistent somatizers other symptoms were equally, or even more, frequent. Thus, the present findings do no support the use of exactly these symptoms as a means to isolate a specific type of clinical conditions, because only patients with that particular predefined symptom profile will be included, whereas similar cases will be excluded. A simple counting of the number of medically unexplained symptoms and number of organ systems the symptoms refer to might increase the sensitivity of the criteria. In contrast to other reports [ 33, 341 gender had no influence on the number of registered diagnoses or symptoms among the persistent somatization patients despite the fact that the males do not have the possibility of gynaecological diagnoses and symptoms. Consistent with other observations [33, 341 the number of different symptoms and diagnoses increased with age. It has been discussed whether there is a physical basis for the somatizing patients’ symptoms in the forrn of minor bodily sensations or banal malaise (virus infections etc that are misinterpreted or aggravated by the patients so that they are mistaken for a serious somatic disorder [7, 35, 361 This question cannot be answered fully on the basis of the observations in this report as it is impossible objectively to verify many single symptoms (e.g. pain, itch, dizziness, dysuria). However, 42 (75%) of the persistent somatizers had been admitted with at least one diagnosis both medically explained and unexplained. Ten of these had when admitted with a medically explained disorder also been admitted with the same illness picture medically unexplained. The interpretation of this might be that these patients use existing symptoms, caused by genuine physical disorders in their somatization. In this way somatization may be looked upon as an unspecific process where the physical symptoms have no symbolic significance for the patients as stated in the psychodynamic theory 1371 . However, the persistent somatizers in general seemed to present a different illness picture when admitted with medically explained disorders compared with their admissions for which no adequate medical explanation could be found, as only nine (16%) of the persistent somatizers had been admitted with more than one diagnosis both medically explained and unexplained. Ten (18%) of the persistent somatizers were on at least one admission discovered to have intentionally self-induced diseases, self-inflicted lesions, to have simulated a physical illness, or to have manipulated paraclinical tests (only cases where the patients denied the self-infliction to the doctor are included). An obvious motive was detected in only one of these patients, who was imprisoned, but after the release he was admitted several times due to intentionally self-induced disease without any obvious motive. The number of patients who had produced factitious objective symptoms were probably underestimated as they were only registered if clear evidence was present. No distinction was made between consciously or unconsciously produced subjective symptoms because this distinction is very difhcult, especially on the basis of record material. Therefore the number of patients with factitious disorder according to DSM-III-R criteria may be even greater. The patients with factitious production of objective symptoms on at least one admission had a tendency to have a larger number of medically unexplained admissions, more different symptoms and
Physical
complaints
of somatizing
patients
135
compared with the other persistent somatizers. This may raise the question whether factitious disorder is a specific diagnostic entity or only a more severe form of somatization. To sum up, the persistent somatizers were characterized by multiple medically unexplained symptoms from many organ systems that could mimic nearly any physical disorder. The use of particular illness. patterns or physical symptoms (‘classic’ conversion symptoms, pain symptoms etc) in diagnosing persistent somatization illness and in distinguishing between the different types of somatization syndromes was not supported by the data in this report.
diagnoses
Ackno~~,~~~~ements-The investigation was supported by the Danish Medical Research Council (12.5771), the Medical Research Fund in the County of Vejle, and the Research Fund at the Hospital of Horsens, Denmark. REFERENCES syndrome. hnce/ 1951; i: 339-341. 1. ASHER R. Munchausen’s characteristics of ‘crocks’. Psych& Med 1970; 1: 15-25. 2. LIPWT DR. Medical and psychological problem patients. Munchamen’s syndrome 1957; 165: 927-933. 3. CHAPMAN J. Peregrinating syndrome). J Ment Sci 1962; 108: 4. BARKER JC. The syndrome of hospital addiction (Munchausen 167. 5. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders Third Edition revised (DSM-III-R). Washington, D.C.: American Psychiatric Association, 1987. a borderland between medicine and psychiatry. Can Med Assoc J 1986; 6. LIPOWSKI ZJ. Somatization: 135: 609-6 14. Br J Psychiat 1976: 129: 55-60. 7. MAY~UR R. The nature of bodily symptoms. states. Br J Psychiat 1976; 129: 1-14. 8. KENYON FE Hypochondriacal by somatizing patients. Psych& Med (in press). 9. FINK P. The use of hospitalizations af Landspatientregisteret 10. SUNDHEDSSTYRELSEN (THE NATIONAL BOARD OF HEALTH). Evaluering (An evaluation of the National Patient Register). Sundhedsstyrelsen 1984; II: 19. indlzggelser pB somatisk afdeling i en 8-3rig periode. En patientregister11. FINK P. 17.49.ariges undersagelse. (With an English summary). Ugeskr Lueger 1989; 151: 307-310. with mental illness. PsychoI Med 1990; 20: 829-834. 12. FINK P. Physical disorders associated Acta Psychicrt 13. FINK P. Mental illness and admission to general hospitals. A register investigation. Scund 1990; 82: 458-462. 14. GUZE SB. The diagnosis of hysteria: What are we trying to do? Am J Psychiat 1967; 124: 491-498. Baltimore: Williams and Wilkins, 1967. 15. FEINSIEIN AR. Clinical Judgement. 1985 printing. Berkeley: University of California 16. DIXON WJ, Editor. BMDP Stutisticui Software. Press, 1985. symptoms: DSM-III diagnoses 17. SLAVNEY PR. TIX~~LBAUM ML. Patients with medically unexplained and demographic characteristics. Gen Hasp Psychiat 1985; 7: 21-25. on clinical aspects of hysteria. A quantitative 18. PURTEL.L. JJ, ROBINS E, COHEN ME. Observations study of 50 hysteria patients and 156 control subjects. JAMA 1951: 146: 902-909. 19. MAI FM, MERSKEY H. Briquet’s treatise on hysteria. Arch Cm Psychiat 1980; 37: 1401-1405. 20. PERIXY MJ, GUZE SB. Hysteria - the stability and usefulness of clinical criteria. N~M. Engl J Med 1962: 266: 422-426. 21. MARTIN RL, CLONINC~ER R, GUZE SB. The evaluation of diagnostic concordance in follow-up studies: II. A blind, prospective follow-up of female criminals. J Psychiat Res 1979; 15: 107-125. 22. CARRODUS AL, EARLAM MSS. Haematuria as a fealure of the Miinchausen syndrome: Report of a case. Aust NZ J Surg 1971; 40: 365-367. 23. CAVENAR JO, MALTBRITE AA, HILLARD JR, WORCHEL BJ, O’SHANICK GJ. Cardiac presentation of Munchausen’s syndrome. Psychosomatics 1980; 21: 946-948. 24. LAZAR RB. Munchausen syndrome presenting as acute spinal cord injury. Arch Phys Med Rehab 1986; 67: 568-569. 25. STERN TA. Munchausen’s syndrome revisited. Psychosomatics 1980; 21: 329-386. without hysteria: A case report and review of the literature. 26. SHALEV A, MUNITZ H. Conversion Br J Psychiaf 1986; 148: 198-203. 27. MCKEGNEY FP. The incidence and characteristics of patients with conversion reactions: I. A general hospital consultation service sample. Am J Psychicit 1967; 124: 542-545.
136
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28. GULE SB, WOO~RU~F RA, CLAYTON PJ. Hysteria and antisocial behavior: Further evidence of an association. Am J Psvchial 1971; 127: 957-960. 29. FOI.KS DG, FORD CV, REGAN WM. Conversion symptoms in a general hospital. P.s\choso,nc~ric~s 1984; 25: 285-295. 30. FORD CV. The somatizing disorders. Psychosomcrfics 1986; 27: 327. 3 I. FOI.KS DG. Conversion disorders: An overview. Ps~chosomntic.s 1985: 26: 37 l-383. 32. DES~UZA C, OTHMER E. Somatization disorder and Briqnet’s syndrome. Arch Grrr P,yychiut 1984; 41: 334-336. 33. GUZF. SB, WOODRUPF JR, RA, CLAYTON PJ. Sex. age, and the diagnosis of hysteria (Briquet’s syndrome). Am J Psychiar 1972; 129: 121-124. 34. ES~OBAR JI, BURNAM MA, KARNO M, FORSYTHE A, GOLDING JM. Somatization in the community. Arch Gen fsychiat 1987: 44: 713-718. 35. PILOWSKY 1. Abnormal illness behaviour. Br J Mcd Psycho/ 1969; 42: 347-351. 36. HANSEN EB. Paranoia hypochondriaca. Krabenhavn, Rishospitalet, psykiatrisk afdeling
Copenhagen: Copenhagen University Hospital, Psychiatric 37. FREUD S, BREUER J. Studies on hysteria. In: Complete Hogarth Press, 1955.
department Psychological
0,
0.
1976.
1976. Works
Vol.
2. London:
PHYSICAL
COMPLAINTS
1992. 0
AND SYMPTOMS
LXX-3999/92 $5.00+ 00 1992 Pergamon Press plc
OF SOMATIZING
PATIENTS PER FINK (Received
22 January 1991;
accepted
in
revised
form
26 June
1991)
Abstract-The purpose of the study was to describe the physical complaints and symptoms of persistent somatization patients. Individuals in the general population (age 17-49 yr) with at least 10 general admissions during an S-yr period were studied. Persistent somatizers (i.e. patients with more than six medically unexplained general admissions) were compared with patients whose admissions could be ascribed to well-defined somatic disorders. Somatizers were characterized by multiple symptoms from many organ systems, and their physical complaints simulated most types of somatic disorder. Although some symptoms were more common than others, none were infrequent, so neither ‘classic’ conversion symptoms nor pain symptoms were found to be especially characteristic of the persistent somatizer. Gender had no influence on number of registered symptoms, whereas the number increases with age. The finding question the use of a predefined symptom checklist in the diagnostic criteria for somatizing disorder. The major part of the somatizers present a different illness picture when admitted with medically unexplained disorders compared with admission for which no adequate medical explanation could be found. However, one fifth had, when admitted with a medically explained diagnosis, also been admitted with the diagnosis medically unexplained at another admission. One fifth of the persistent somatizers had been admitted at least once for factitious illness, but apart from the fact that they had more symptoms and admissions, they did not differ from the other persistent somatizers.
INTRODUCTION
complaining of physical illness or symptoms that cannot be explained by a detectable somatic disease or pathophysiologic mechanism have been described under many different labels such as Munchausen’s syndrome [ 11, hysteria, crocks [ 21, peregrinating problem patients [ 3 ] , hospital addiction [ 41. In DSM-III-R they are mainly categorized under one of the somatoform disorders, chronic factitious disorder or somatic delusions [5] . In this report the term somatization patients will be used according to the definition given by Lipowski [6 ] . There is some confusion and disagreement on the diagnostic criteria for the different syndromes and there has been a high degree of overlapping. The type and the character of the somatic symptoms (e.g. pain, conversion symptoms), and the way they are presented and produced by the patient (e.g. self-induced/inflicted, unconscious/conscious) plays a major role in diagnosing and in distinguishing between the syndromes [6-81. The diagnostic categories or syndromes are mainly developed on the basis of observation done among patients attending to psychiatric setting or on the basis of case reports. Because somatizing patients present primarily to non-psychiatric physicians and may refuse psychiatric referral, a non-psychiatric setting would be a more ideal setting for the study of somatization illness. Recently a study was carried out on 282 individuals with a heavy utilization of general in-patient admissions (10 or more during an 8-yr period). Approximately PATIENTS
Institute
of Psychiatric
Demography,
Aarhus
Psychiatric 12.5
Hospital,
DK-8240
Risskov,
Denmark
126
PER FINK
20% of these patients had no physical disorder that could adequately explain their multiple admissions [ 91 . The aim of this report is to describe the physical symptoms and illness complaints that had brought these patients to hospital. The sociodemographic characteristics as well as age at onset and utilization of admissions of these patients have been described elsewhere [9] METHOD The population basis consists of all 17-49 yr olds living in two Danish municipalities (15.609 men and 14,818 women, age on 1 January 1984). The hospitalizations of the population cohort were followed during the period 1977-1984 by means of The National Patient Register. This is a nationwide patient register where all in-patient admissions to non-psychiatric departments in Denmark smce 1977 are registered [lo] The data are person identifiable by the CPR number (central person registration number) which is a number all Danes get at birth. The results on the patient register investigation have been reported elsewhere 19, 1l-131. In the present study are included the approximately 1% (N = 282) of the general population with IO or more general admissions during the S-yr period. Since the topic for this investigation was somatization, patients whose course of illness could be ascribed to a somatic disease with a high diagnostic reliability or well-established treatment routines were excluded on the basis of discharge diagnosis in the National Patient Register. Diseases which led to exclusion (number of patients in parentheses) were*: diabetes mellitus (41), colitis ulcerosa (5), malignant tumours (27), uraemia (9), haemophilia (2), desensitization treatment (6), fractures (45). various other well-defined diseases (7). Moreover one patient treated for manic-depressive psychosis at a non psychiatric department was excluded. One more patient was excluded because access to her medical record was refused by the department. Thus, the study population consisted of 138 patients, whose medical records were reviewed covering all admissions to general hospital from birth to 31 December 1984. Admissions previous to the establishment of the National Patient Register in 1977 were traced through information about ‘previous illness’ which is a standard item in Danish medical records. Admissions to out-patient units were not registered if they led to hospitalization or were part of an aftercare or checkup. The 138 patients had in total 2930 genera! in-patient and 93 out-patient admissions from birth to 1985 (excluding admissions due to pregnancy, abortions and sterilizations). Based upon a data extraction from the medical records it was registered for each crdmissiun whether it: (a) Was caused by physical symptoms/complaints that could not be explained adequately by any detectable somatic disorder (i.e. medically unexplained) (N = I, 126). In this report ‘no adequate medical explanation’ means that the complaints were considered to be grossly in excess of what one would expect on the grounds of objective medical findings (e.g. ‘3 years after the relatively moderate trauma of the knee joint, the patient still has subjective complaints which do not correspond to the objective findings, a slight atrophy of the quadriceps’). If it was unclear (which was the case in 8% of the admissions) whether an admission was adequately explained by somatic disease or not. it was placed in category (a). Self--inflicted lesions/diseases where the self-infliction was denied by the patient (factitious disease) fell in category (a). (b) Was caused by a somatic verifiable disease (i.e. medically explained) (N = 1,321). (c) Was a straightforward psychiatric case (N = 576). Admissions due to self-destructive acts (suicidal attempt, self-mutilation), alcoholism and drug dependence or complications to these (cirrhosis hepatitis, chronic pancreatitis) were placed in this category. In these cases both the patient and the physicians were fully aware of the psychiatric caseness wherefore the question: somatization or genuine somatic disorder. was irrelevant. The medical records from the general hospital primarily serving the patients resident in the area were first reviewed. If it could be certified on this basis that the admissions were not due to somatization, only discharge letters of admission to other hospitals were obtained and no symptoms were registered. However, if information in the discharge letters raised the question whether the admissions were adequately explained by a somatic disease or was due to straightforward psychiatric admissions, the complete medical records were obtained and symptoms were registered. For each admission a diagnosis representing the pattern of illness of a somatic disorder causing the admission was registered (admission diagnosis). In cases of a verifiable somatic disease the department discharge diagnosis was used. If the admissions were caused by a complication to a chronic disease the
*Details
concerning
the operationalizing
criteria
can be requested
from the author
Physical
complaints
of somatizing
patients
127
diagnosis of this was used. If no verifiable physical disease was detected the tentative diagnosis of the department was used, or in cases where the tentative diagnosis was undescriptive (e.g. observation), the admission diagnosis given by referring physician was used. The complaints were registered on a list of 67 predefined symptoms plus 6 ‘other’ symptoms distributed according to organ system. * Only symptoms which either the physician or the patient attributed to the physical illness that had caused the admission were registered. After the review of the medical records it was clear that a group of the patients were straightforward psychiatric cases, i.e. the main part of their admissions were due to substance abuse, suicidal attempt etc. (category c admissions). Since the topic for this report was somatization, patients with less than 10 admissions due to physical symptoms or complaints were excluded. Twenty-five patients were excluded by this criterion and they had all at least six straightforward psychiatric admissions (category c admissions) and no more than four admissions due to medically unexplained physical complaints. The remaining 113 patients had at median six medically unexplained admissions in a lifetime. Patients were grouped as persistent somatizers (som) (N = 56) if they had more than six admissions due to medically unexplained physical complaints or symptoms and as non-somatizers (N = 57) if six or less. For a more detailed discussion on the grouping of the patients see elsewhere [9] Nine of the persistent somatizers were males. 47 females against 24 and 33, respectively, of the non-somatizers 0, < 0.01). The median age of the persistent somatizers was 35.8 yr against the non-somatizers 40.8 yr. The difference was not statistically significant controlling for gender 0, > 0.05). Seventy per cent (1,016) of the persistent somatizers’ admissions were medically unexplained, 163 (1 1%) due to straightforward psychiatric admissions against 86 (8%) and 50 (5 %) respectively, of the non-somatizers. In this report conversion symptoms only means ‘classic’ conversion symptoms, i.e. medically unexplained symptoms suggesting a neurologic disease [ 141. Factitious illness in this report only includes disorders resulting from self-inflicted illness where the self-infliction is denied by the patient and illness suspected on the basis of the patient’s manipulation with objective symptoms (for definition of objective symptoms see Ref. [ 151). No attempt was made to distinguish between unconsciously or intentionally produced symptoms. Statistics The data were processed by means of the BMDP Statistical Software [ 161 Multiway interactions between variables were investigated by means of hierarchical log linear analysis of contingency tables with stepwise backward elimination of interactions using the 4F programme in BMDP. Two-way interactions using the 4F programme in BMDP. Two-way interactions between variables were depending on the distribution tested by chi-square test, Fisher’s exact test (two-tailed), or Mann-Whitney U-test. Ninety-five per cent confidence limit was used.
RESULTS
Admission
diagnoses
In Table I the admission diagnoses are divided into 38 categories distributed according to organ system. The percentage of the persistent somatizers admitted at least once with the diagnosis and the percentage of the persistent somatizers’ total number of admissions where the diagnosis was used is shown for each diagnostic category. Gastrointestinal diagnoses were the most common admission diagnoses as 96% of the persistent somatizers had been admitted at least once with this diagnosis. More than 90% had been admitted at least once with the diagnosis medically unexplained. In total these diagnoses account for more than VI of the persistent somatizers’ admissions. Compared with the non-somatizers the persistent somatizers had a 24 times higher risk (i.e. OR = 24) of having been admitted with a gastrointestinal diagnosis, either medically explained or unexplained. It is seen that unspecific abdominal pain accounts for 14% of the persistent somatizers’ admissions and 3/4of the patients had
*Complete
list of symptoms
can be requested
from the author
PER FINK
128 TABLE
I.-ADMISSION
(OR .r”wrArtv”
DIAGNOSES) OF THE PEastsrnNT
Percentage of patients at least once admitted diagnosis
(N = 56) with the
S~MAT~ZAT~ON
PATIENTS
Percentage of admissions (N = 1,473) with the admission diagnosis ___Medically I” Som vs unexplained total? nsom % % OK1
Medically unexplained E
I” total? %
Som vs “som GKi
91.1
96.4
24.4***
25.7
28.7
4.6***
76.8 25.0 23.2
76.8 33.9 25.0
15.6*** 3.7** 2.0
13.8 1.2 4. I
13.8 1.6 4.4
14.1*** 2.1 3.2***
19.6
30.4
1.8
2.7
4.2
17.9 12.5 8.9
17.9 12.5 19.6
6.0** 8.0* 1.7
I .4 1.1 1.4
1.6 1.1 2.0
diseases!
87.2
93.6
5.5**
13.4
16.1
Menstrual irregularity Salpingo-oophoritis acuta Other gynaecological diseases Extrauterine pregnancy Mamma tumor”, hypertrophia, infections
70.2 21.3
74.5 23.4
3..5** 2.2
9.2 1.4
9.5 I .5
1.8** 0.8
19.1 17.0
38.3 19.1
0.7 3.7
0.9 1.1
2.4 1.4
0.3*** 3.7
8.5
17.0
1.1
0.8
1.4
1.1
Admission
diagnoses
I Gastrointestinal
diseases
Abdominal pain Appendicitis Gastrointestinal ulcer Other GI diseases (including liver, gall, pancreas) Diarrhoea, anorexia, malabsorption Cholelithiasis/cholecystitis Anal diseases II Gynaecological
III CNS diseases Epilepsy, convulsions CNS traumas Headache Other CNS diseases Fainting Neuritis/neuralgia, nerve-root compression Multiple sclerosis IV Musculo-skeletal
diseases
Back pain (incl. disc) Other traumas Knee diseases Other musculo-skeletal diseases V Urinary
system
diseases
Pylero-nephritis, cystitis urolithiasis Urine incontinence/urine retention, other urinary diseases Kidney/urinary system, venereal diseases VI Endocrine, febrilia, metabolic diseases
-
1.2 8.8*** I I .6*” 2.1* 1.1
71.4
80.4
5.2***
9.8
13.4
0.6***
26.8 25.0 21.4 21.4 19.6
26.8 37.5 23.2 21.4 19.6
3.1* 3.2** 5.4** 1.3 3.2*
2.0 1.5 1 .o 1.2 1.6
2.6 3.2 1.1 2.2 1.6
0.7 0.8 3.9* 0.3*** 4.4**
14.3 7.1
17.9 7.1
3.9* 2.1
1.1 1.5
1.2 1.5
0.8 0.8
62.5
78.6
1.6
9.8
13.2
0.4***
26.8 26.8 19.6
26.8 44.6 23.2
0.5 I .6 I .9
4.9 1.8 2.3
5.3 3.6 3.0
0.3*** 0.4*** 2.0*
12.5
17.9
0.9
0.9
1.3
0.2***
41.1
42.9
I.8
6.2
6.8
0.8
32.1
32.1
4.0**
4.3
4.6
1.5
16.1
16.1
-**q
1.7
1.8
_***q
7.1
10.7
0.4
0.3
0.4
0.1***
19.6
25.0
2.4
1.4
1.7
1.5 (Continued).
Physical
TABLE
complaints
of somatizing
patients
129
I.-CONTINUED
Percentage of patients at least once admitted diagnosis
Admission
Medically unexplained %
diagnoses
VII Skin diseases Skin diseases Abscesses/lymphangitis VIII Cardiac
diseases
Cardiac ischaemic disease Other cardiac diseases IX Eye/ear/nose, diseases X Pulmonary
In totalt %
(N = 56) with the Som vs nsom OR$
Percentage of admissions (N = 1,473) with the admission diagnosis Medically unexplained %
In totalt %
Som vs nsom ORI:
14.3
25.0
1.4
1.4
2.9
0.8
8.9 5.4
21.4 8.9
1.7 1.8
0.7 0.7
2.0 0.9
0.6* 3.1
10.7
10.7
I .2
1.1
1.2
8.9 1.8
8.9 5.4
5.5 0.6
1.0 0.1
1.0 0.2
10.9*** 0.1***
10.7
19.6
3.2”
0.5
1.1
0.6***
7.1
16.1
0.5
1.5
5.9
0.5***
5.4 3.6
12.5 5.4
0.4 0.8
0.3 1.2
1.o 4.9
5.4*** 0.9
I
10.7
2.2
0.4
0.7
0.2***
0.6
throat
diseases
Other pulmonary Asthma
diseases
XI Blood diseases,
phlebitis
7.
attempts
-
50.0
3.4**
11.1
3.4***
-
46.4 8.9 7.1
3.6”* 1.0 2.1
10.3 0.5 0.3
4.7*** 0.2*** 0.9
XII Abuse,
suicidal
Poisoning Alcoholism Drug dependence
-
*p < 0.05, **p < 0.01) ***p < 0.001. iEither medically explained or unexplained. *Odds ratio for the persistent somatizer of having been admitted with the diagnoses compared to the non-somatizer. SPercentage of females only. (None of the non-somatizers had been admitted under the diagnosis and therefore no odds ratio was calculated. been admitted with this diagnosis at least once. Among the females almost as great a percentage has been admitted due to symptoms suggesting a gynaecological disorder. But in contrast to the gastrointestinal diseases it is seen that these diagnoses do not account for a greater number of the persistent somatizers’ admissions than of the non-somatizers’ (OR = 1.1) despite the fact that significantly more of the persistent somatizers had been admitted with the diagnosis (OR = 5.5). Central nervous system diagnoses were the third most common admission diagnoses, but except for headache and fainting the CNS diagnoses account for a greater number of the nonsomatizers’ admissions than of the persistent somatizers. Further it is seen that half of the persistent somatizers had been admitted at least once because of poisoning, alcoholism or drug dependence. In general Table I shows that the group of persistent somatizers had their admissions attributed to a wide range of diagnoses and none of the diagnoses were uncommon. At median eadl persistent somatizer had during admissions been diagnosed with 8 (Ql-Q3: 6-11 max. 21) different diagnostic categories either medically
PER FINK
130
explained or unexplained which was significantly more than the non-somatizer (median 5, Ql-Q3: 3-6 max. 10) @ < 0.000). Looking at the 12 organ system categories only, the somatizer had been hospitalized for diagnoses belonging to median 5 (Ql-Q3: 4-6 max. 10) organ systems and the non-somatizer median 3 (Ql-Q3: 2-4.5, max. 6) CJI< 0.000). Gender and number of admissions had no influence on the number of diagnoses whereas there was a small, but statistically significant increase in the number of different diagnoses by age among the group of persistent somatizers, but not among the non-somatizers. Figure 1 shows that each persistent somatizer’s most frequently occurring diagnostic category at median accounts for 33 % of the admissions, the two most frequent diagnostic categories for 55 % etc. It is seen that the admissions of the non-somatizers were explained by diagnoses belonging to significantly fewer diagnostic categories (Mann-Whitney U test separately for each number of diagnoses, all p < 0.000). No significant sex or age differences were found in this aspect.
I
I 1
O
I
I
I
I
I
I
I
2
3
4
5
6
7
6
Priority of diagnoses
0 FIG. 1. Cumulative
Persist. somatizer
I
x Non-somatizer
QlU3
percentage nf each patient’s admkions
(median)
explained
by number of diagnoses.
Do the persistent somatizers present the same illness picture on their medically explained and their medically unexplained admissions? Leaving out admissions due to substance abuse and suicidal attempt, the persistent somatizers at median had been admitted with six (Ql-Q3: 5-S) different medically unexplained diagnoses, two (QlQ3: l-3) different medically explained diagnoses and one (Ql-Q3: O-l) diagnosis which had been both medically explained and unexplained (i.e. on one admission medically explained, but on another medically unexplained). Only nine (16 o/o, including four of the nine males) had been admitted with more than one diagnosis both medically explained and unexplained. However, 12 (21%) all females) of the persistent somatizers who had been admitted with a medically explained disorder had also been admitted on another occasion with the same diagnosis medically unexplained. Symptoms
In Figure 2 the persistent somatizers’ primary symptom complaints are shown for admissions other than those with a diagnosis of substance abuse or poisoning.
Physical complaints of somatizing patients percentage patients
131 percentage
Of (n-56j2
admissions
Cl
(n-1271J3
r
CNS Anaesthesia Vision disturbances Syn kope paresis Urinary retention Convulsions Amnesia Ataxla Other symptoms Tremor Unconsciousness Confusion Aphasia PAIN Gastrcintestlnal Extremities Headache Cardiopulmonal UrOgenltaI GASTROINTESTINAL Upper abdomen Diarrhea Other (-paIns) Obatipatlcn Borborhygmla Melaena Haematemesi8 UNSPECEFIC Fstlgue Fainting Few L0e.a of weight UROGENITAL symptoms+ Dlsoh.rge4 Dysuria4 Dyspareunla Other symptoms urine Incontfnence
r
Menstrual
4
SKIN - EXTREMITIES Wounds-suggllatlon Function dlfflculty Other aymptomn CARDIOPULMONARY Dyspnoea Other symptoms Cough OTHER
ORGAN
SYSTEMS 100%
60%
60%
40% Medical.
20%
0%
unexplained
20% Kiln
40% total
Complaints which the physician or the patient attributes to the illness as causina the admission. Admissions due to substance abuse, poisoning and pregnancy are excluded Percentage of the persistent somatizers who had the complaint on at least one admission Percentaqe of the persistent somatizers' admissions where the symptoms are registered Percentage of females only FIG.2. Primarysymptom complaints of thepersistent somatizers.
Apart from convulsions, tremor, unconsciousness, CNS symptoms, cardiopulmonary and ‘other’ urogenital
confusion, symptoms,
aphasia, ‘other’ all the symptoms
132
PER FINK
were registered at least once among significantly (p < 0.05 Mann-Whitney test) more of the persistent somatizers than among the non-somatizers (either medically explained or unexplained). Only vision disturbances, gastrointestinal pain, upper gastrointestinal symptoms (i.e. nausea, vomiting, pyrosis), ‘other’ GI symptoms, dizziness and dysuria were seen at a significantly greater number of the persistent somatizers’ admissions. On the other hand, several of the other symptoms (Fig. 2) were registered at a significantly greater number of the non-somatizers’ admissions. Eighty-nine per cent of the persistent somatizers had on at least one medically unexplained admission a complaint of one of the ‘classic’ conversion symptoms (i.e. the symptoms listed under ‘CNS’ excluding ‘other’) and one of these symptoms was registered at 115of the group of persistent somatizers’ admissions. The most frequent symptom registered was gastrointestinal pain which was registered at 49% of the group of persistent somatizers’ admissions. The persistent somatizers had throughout their admissions at median 22.5 (QlQ3: 19-29, max. 40) different symptoms (out of 73 possible) against the nonsomatizers’ 11 (Ql-Q3: 6.5-14.5, max. 26). The number of registered symptoms correlated to a certain degree to number of admissions, but the difference was significant even when comparing patients from the two groups corrected for number of admissions @ = 0.007). The number of registered symptoms was not related to gender whereas the number of symptoms increases significantly with age among the persistent somatizers, but not among the non-somatizers. Factitious
illrws
Intentionally self-inflicted diseases or lesions simulating a disease were discovered in five of the persistent somatizers (three females, two males). One patient had a selfinduced anal dermatitis and one had by scratching induced lesions simulating a universal dermatitis. Further one patient had been admitted with a universal dermatitis which was caused by abuse of diuretica. Two patients had created multiple abscesses with a needle. One of these patients further simulated an arthritis by selftraumatizing and simulated a fever. Nine of the persistent somatizers (including four of the five above-mentioned patients) (two males, seven females) were discovered on at least one admission to have manipulated with objective symptoms or signs. One patient had induced haematuria, one patient simulated haematemesis several times by eating elderberry syrup, and nine patients had on at least one admission simulated In total ten (18%) of the persistent fever by manipulation of the thermometer. somatizers had thus been admitted at least once to factitious illness, in four patients, however. only discovered at one admission. Further, one of the non-somatizers was found to have simulated a fever at one admission. The patients admitted due to factitious illness did not differ from the other persistent somatizers as to age and gender, but had more admissions (p < 0.05) and a nonsignificant tendency towards more different diagnoses and symptoms. DISCUSSION
Persistent somatizers were in this report defined as patients with more than six general admissions for medically unexplained physical symptoms. The patients were selected from a general population and they were followed in their lifetime before
Physical complaints of somatizing patients
133
1985, covering all admissions to all types of non-psychiatric departments. In this respect this report differs methodologically from all other studies which deal mainly with patients referred to or attending a psychiatric service [ 17-201 . The physical complaints of the patients were described using either diagnostic labels and/or symptoms. Such an approach has advantages as well as disadvantages. A diagnostic label transmits a rapid understanding of the way the physician sees the problem which is presented to him and contains more information than a simple list of symptoms [ 1.51. On the other hand, the tentative diagnosis will depend on the viewpoint and the skills of the physician (i.e. a gynaecological specialist will think of a gynaecological disorder as a first choice) whereas symptoms will give a more objective description. Since this investigation is based on record material the number of symptoms probably tends to be underestimated as the patients were not asked about all possible symptoms, and statements like ‘the patient complains of numerous symptoms from many organ systems’ were not infrequently seen in the records. On the other hand Martin et al. [ 2 1 ] found that independent medical records often revealed much more unexplained complaints than were reported by the patients at the diagnostic interview for Briquet’s syndrome. Looking at the persistent somatizers as a group, the data show that although some symptoms were more common than others, none were infrequent and that the physical complaints of the persistent somatization patients may mimic almost any somatic disorder. Also on an individual basis the persistent somatizers were characterized by having multiple complaints from many organ systems whether counting each patient’s number of symptoms or number of received diagnostic labels. Dividing somatization syndromes into different subtypes on the basis of the physical complaints (i.e. neurologic, haemorrhagic, abdominal etc.) [22-251 thus seems to be a useless task, as the patient on one admission will belong to one subtype, but on another to a different subtype. ‘Classic’ conversion symptoms (i.e. medically unexplained symptoms suggesting a neurological disorder [5, 141 has traditionally had a dominating role in the diagnosis of hysteria [26] The present study does not support the theory that ‘classic’ conversion symptoms could be more characteristic of hysteria (or somatization) than of other medically unexplained symptoms, since the latter were just as frequent, or even more frequent, among the persistent somatizers than the ‘classic’ conversion symptoms. Furthermore, none of the persistent somatizers were of monosymptomatic ‘conversion types’. Since other reports have not demonstrated any correlation between the occurrence of conversion symptoms and correlation between the occurrence of conversion symptoms and hysteria or a hysterical personality [ 26-3 1 ] the theory of a correlation may be ascribed to the lack of representative empirical data on the subject. The term hysteria has now been eliminated as obsolete [ 61 and replaced by other diagnostic categories in DSM-III-R, mainly somatization disorder. The diagnostic criteria for this disorder are that the patients must have at least 13 medically unexplained physical symptoms out of a list of 35 predefined symptoms [5]. The criteria are a modification of the criteria previously established by Perley and Guze [ 201 to define Briquet’s disorder [ 321. Perley and Guze based their work on observations done by Briquet, Pm-tell et al. and Robins and O’Neal [ 201, who registered
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the symptom complaints among patients who were referred to psychiatric services and were given a diagnosis of hysteria. The present report on patients attending nonpsychiatric hospitals shows that although the 35 predefined DSM-III-R symptoms were frequent among the persistent somatizers other symptoms were equally, or even more, frequent. Thus, the present findings do no support the use of exactly these symptoms as a means to isolate a specific type of clinical conditions, because only patients with that particular predefined symptom profile will be included, whereas similar cases will be excluded. A simple counting of the number of medically unexplained symptoms and number of organ systems the symptoms refer to might increase the sensitivity of the criteria. In contrast to other reports [ 33, 341 gender had no influence on the number of registered diagnoses or symptoms among the persistent somatization patients despite the fact that the males do not have the possibility of gynaecological diagnoses and symptoms. Consistent with other observations [33, 341 the number of different symptoms and diagnoses increased with age. It has been discussed whether there is a physical basis for the somatizing patients’ symptoms in the forrn of minor bodily sensations or banal malaise (virus infections etc that are misinterpreted or aggravated by the patients so that they are mistaken for a serious somatic disorder [7, 35, 361 This question cannot be answered fully on the basis of the observations in this report as it is impossible objectively to verify many single symptoms (e.g. pain, itch, dizziness, dysuria). However, 42 (75%) of the persistent somatizers had been admitted with at least one diagnosis both medically explained and unexplained. Ten of these had when admitted with a medically explained disorder also been admitted with the same illness picture medically unexplained. The interpretation of this might be that these patients use existing symptoms, caused by genuine physical disorders in their somatization. In this way somatization may be looked upon as an unspecific process where the physical symptoms have no symbolic significance for the patients as stated in the psychodynamic theory 1371 . However, the persistent somatizers in general seemed to present a different illness picture when admitted with medically explained disorders compared with their admissions for which no adequate medical explanation could be found, as only nine (16%) of the persistent somatizers had been admitted with more than one diagnosis both medically explained and unexplained. Ten (18%) of the persistent somatizers were on at least one admission discovered to have intentionally self-induced diseases, self-inflicted lesions, to have simulated a physical illness, or to have manipulated paraclinical tests (only cases where the patients denied the self-infliction to the doctor are included). An obvious motive was detected in only one of these patients, who was imprisoned, but after the release he was admitted several times due to intentionally self-induced disease without any obvious motive. The number of patients who had produced factitious objective symptoms were probably underestimated as they were only registered if clear evidence was present. No distinction was made between consciously or unconsciously produced subjective symptoms because this distinction is very difhcult, especially on the basis of record material. Therefore the number of patients with factitious disorder according to DSM-III-R criteria may be even greater. The patients with factitious production of objective symptoms on at least one admission had a tendency to have a larger number of medically unexplained admissions, more different symptoms and
Physical
complaints
of somatizing
patients
135
compared with the other persistent somatizers. This may raise the question whether factitious disorder is a specific diagnostic entity or only a more severe form of somatization. To sum up, the persistent somatizers were characterized by multiple medically unexplained symptoms from many organ systems that could mimic nearly any physical disorder. The use of particular illness. patterns or physical symptoms (‘classic’ conversion symptoms, pain symptoms etc) in diagnosing persistent somatization illness and in distinguishing between the different types of somatization syndromes was not supported by the data in this report.
diagnoses
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