28 Medically unexplained symptoms in women

The concept of medically unexplained symptoms (MUS) covers a broad range of phenomena. Both subjective complaints (e.g. psychogenic pain) and objective physical (pseudoneurological) symptoms of motor and/or sensory type (conversion disorder) may belong to this spectrum. MUS constitute somatoform disorders in psychiatric nosology. Covering multiple bodily symptoms of both objective and subjective type, somatization disorder is the most severe end of this spectrum. There are also MUS not covered by psychiatric nomenclature, such as irritable bowel syndrome and fibromyalgia (Wessely et al. 1999). They are thought to be as physical conditions affected by psychological factors (formerly psychosomatic disorders).

All somatoform disorders are more common among women than men in the general population; in one study, somatization and conversion disorders were seen only among female participants (Faravelli et al. 1997). In another study, gender rate of somatoform pain disorder was 2:1 in the general population (Grabe et al. 2003a). In a town in western Turkey, the prevalence of conversion disorder was 1.6% among men but 8.9% among women in the general population (Deveci et al. 2007). The age group 15–34 and those who had a mother with a psychiatric disorder were at risk in particular. In medical settings, somatoform disorders among internal medical patients are especially prevalent among young women (Fink et al. 2004). According to medical public outpatient records in Finland, somatization was associated with female sex, lower educational level, and increased psychiatric morbidity (Karvonen et al. 2007). More girls than boys are affected by somatoform disorders also among adolescents (Essau et al. 1999). Thus, the predominance of women among subjects with MUS is a common finding shared by studies in diverse cultures, on various age groups, and both in clinical and non-clinical settings.

Various types of MUS are fare from being rare. However, epidemiological studies are faced with methodological difficulties due to the transient nature of the conversion symptoms. The difficulty of a thoroughly medical follow-up to rule out an organic cause while conducting a screening study in the community based on a structured psychiatric interview also contributes to limitations.

Studies in Western Europe and North America have been focused on somatoform disorders in general. One-year prevalence of all DSM-III-R somatoform disorders was 19.9% in the general population in Florence, Italy (Faravelli et al. 1997). In Germany, the prevalence of somatoform disorders in the community was 19.7% (Grabe et al. 2003b). Representing a problem in psychiatric nosology, most of them were of undifferentiated type.

Among outpatients admitted to a primary health care institution in a semirural area near Ankara, Turkey, the prevalence of conversion symptoms in the preceding month was 27.2% (Sagduyu et al. 1997). The lifetime rate increased to 48.2%. A study conducted on women in the general population of Sivas City in central Turkey (a rather non-industrialized region of the country), 48.7% of participants had a lifetime history of a conversion symptom (Şar et al. 2009).

Among women in Sivas City, Turkey, dizziness and fainting or loss of consciousness were the most prevalent conversion symptoms, 22.9% and 22.1%, respectively (Şar et al. 2009). Non-epileptic seizures or convulsions were reported by 3.8% of the participants. Most of the participants in the conversion group had only one conversion symptom (43.5%), 23.2% of the participants had two, 15.7% had three, and 17.6% of the participants had four or more conversion symptoms. Among subjects with a conversion symptom, 10.5% (n=32) had multiple somatic complaints sufficient to fit the diagnostic criteria of a DSM-IV somatization disorder; i.e. making an overall prevalence of 5.1% in the community. In a psychiatric inpatient setting, however, the most prevalent conversion symptom was pseudoseizure (Şar and Şar 1990).

In a city in western Turkey, the prevalence of DSM-IV conversion disorder was 5.6% in the general population (Deveci et al. 2007). In order to fit the diagnostic criteria, these authors eliminated subjects who did not attribute their physical symptoms to a stressful life event. Screening of both genders, a higher average socioeconomic level, and use of the stressful life event criterion seem to be responsible for the lower prevalence obtained in this study. In fact, pseudoseizure patients are less likely than those with epilepsy to see psychological factors as relevant to their symptoms; they are more likely to deny that they have suffered from life stress (Stone et al. 2004).

In a study on a large group of women in Norway (Eberhard-Gran et al. 2007), all somatic symptoms and several diseases were significantly more common in women exposed to physical/sexual violence as compared to non-exposed women. The impact of violence on somatic symptoms and diseases remained after controlling for depression and sociodemographic factors. The same study documented that 18% of the studied population reported exposure to physical violence and 3% had been forced into sexual intercourse as an adult.

Several studies suggest that not only traumatic experiences in adulthood, but traumatic experiences in childhood also affect both psychiatric and overall health throughout whole life. In evaluation of data collected in the National Comorbidity Survey (Sachs-Ericsson et al. 2005), childhood sexual and physical abuse were associated with one-year prevalence of serious health problems for both men and women. Participants’ psychiatric disorders partially mediated the effects of childhood trauma on adult health; however, childhood abuse continued to independently influence health status after the authors controlled for psychiatric disorders. There is a strong relationship between adverse childhood experiences and adolescent pregnancy (Hillis et al. 2004). Moreover, the negative psychosocial sequelae and fetal deaths commonly attributed to adolescent pregnancy seem to result from underlying adverse childhood experiences rather than adolescent pregnancy per se.

MUS are also frequently associated with a history of traumatization. Chronic pain was associated with childhood physical abuse among women in the community (Walsh et al. 2007). In a chronic pelvic pain population, women with self-reported sexual or physical abuse histories were found to have significantly higher dissociation, somatization, and substance abuse scores than women without such a history. Although a high rate (86%) of traumatic life events are reported by patients with irritable bowel syndrome, only a small percentage of them (7.8%) met criteria of post-traumatic stress disorder (PTSD), a rate close to that in the general population (Cohen et al. 2006). However, high rates of somatization, obsessive–compulsive behaviour, interpersonal sensitivity, and anxiety symptoms were seen among them. There is a strong association between sexual trauma exposure and somatic symptoms, illness attitudes, and healthcare utilization in women (Stein et al. 2004). In this study, sexual assault was associated with a significant increase in somatization scores, physical complaints across multiple symptom domains, and health anxiety. Sexual assault was also a significant statistical predictor of having multiple sick days in the prior six months and of being a high utilizer of primary care visits in the prior six months. Childhood abuse or neglect was associated with increased vasomotor symptom reporting among midlife women (Thurston et al. 2008).

Among women attending a primary care clinic, traumatic events were reported by 81% of the subjects (Escalona et al. 2004). The lifetime prevalence of PTSD was 27%; this rate was 19% for somatization. PTSD was the best predictor of somatization after control for demographic variables, veteran status, and other anxiety and mood disorders. Psychological numbing symptoms of PTSD emerged as a particularly strong predictor of somatization. Somatoform symptoms are more prevalent in traumatized psychiatric patients compared with non-traumatized patients (Sack et al. 2007). There were specific elevations of symptom frequencies for pseudoneurological (conversion) symptoms and symptoms associated with discomfort and dysfunction in sexual organs.

Overall, there is an association between lifelong traumatic experiences and health status including MUS. While being associated with a higher prevalence of MUS compared to men, female gender also constitutes a predisposition for various kinds of psychological trauma in the community (Brand 2003).

Conversion, somatization, and dissociative disorders have a common historical and theoretical origin (Freud 1895/1974; Harris 2005). Among women in the general population in Turkey, 26.5% of the subjects with a conversion disorder had a concurrent DSM-IV dissociative disorder (Şar et al. 2009). In clinical settings, 30.1–50.0% of patients with a conversion disorder had a concurrent DSM-IV dissociative disorder (Litvin and Cardena 2000; Tezcan et al. 2003; Şar et al. 2004). Taking this overlap and the common ground into consideration, several authors suggest that conversion disorder should be classified among dissociative disorders, as in ICD-10 (Bowman 2006; Brown et al. 2007). Moving forward, Nijenhuis et al. (1999) conceptualize conversion phenomena themselves as a kind of somatoform dissociation, in contrast to psychological dissociation. In fact, they are correlated with each other (Nijenhuis et al. 1998). This notion is in accordance with the BASK model of dissociation which points out not only the disconnection between behaviour (B), affect (A), and knowledge (K), but also between them and sensation (S) (Braun 1988).

MUS are extremely common in patients with complex dissociative disorder such as dissociative identity disorder, many of whom also meet diagnostic criteria for somatization disorder (Saxe et al. 1994). Somatoform dissociative phenomena (e.g., anaesthesias, seizures, paralysis, dysphagia) are significantly more common in patients with dissociative disorders than in psychiatric controls and the severity of these symptoms is also correlated with the complexity of the dissociative disorder (Nijenhuis et al. 1999). Significant positive correlations were found between reports of both dissociation and somatization with maladaptive coping strategies and among dissociation, somatization, and substance abuse (Badura et al. 1997).

Although somatization can not be reduced to a dissociative origin, it has a strong link to dissociation. Modern studies demonstrate that patients who have conversion, somatization, and dissociative disorders report childhood abuse and/or neglect frequently (Morrison 1989; Roeloff et al. 2002; Şar et al. 2004, 2007a, 2007b, 2009). In a sample of low-income African-American women, dissociation was related to childhood trauma exposure and mental health symptoms (Banyard et al. 2001).

Physical abuse and life threat posed by a person predict somatoform dissociation best (Nijenhuis et al. 2003). In one study, women with conversion disorder or chronic pelvic pain did not demonstrate a relationship between childhood trauma and dissociation in general; however, somatoform dissociation was related to physical abuse in childhood (Spinhoven et al. 2004). Women with conversion symptom history report all types of childhood abuse and neglect more frequently than non-conversion subjects (Şar et al. 2009). In multivariate analysis, only childhood physical abuse predicted a conversion symptom significantly. Effects of childhood neglect and emotional and sexual abuse, on the other hand, were mediated by lifetime major depression and/or dissociative disorder comorbidity which were two further predictors of a conversion symptom.

Dissociation is a problem for a substantial segment of patients with fibromyalgia and it is related to certain physical symptoms of the disorder (Leawitt and Katz 2003). In a group of female patients, fibromyalgia was associated with increased risk of victimization (Walker et al. 1997). Sexual, physical, and emotional traumas were important factors in the development and maintenance of this disorder and its associated disability in many patients. According to one study, although dissociation, somatization, alexithymia, and depression were distinct syndromes they correlate to a considerable extent (Lipsanen et al. 2004). Proposing a new category of ‘complex’ PTSD, Van der Kolk et al. (1996) underlined that PTSD, dissociation, somatization, and affect dysregulation represent a spectrum of adaptations to trauma; i.e. they often occur together, but traumatized individuals may suffer various combinations of symptoms over time.

One reason to focus on dissociation while inquiring about somatization is its relationship with developmental traumas, dysfunctional attachment, and affect dysregulation. These phenomena appear as significant factors repetitively in empirical studies on MUS. Somatoform disorders are associated with affect dysregulation, including a proneness to experience undifferentiated affects alongside with alexithymia (Waller et al. 2004). Fearful and preoccupied attachment styles are both associated with symptom reporting via a negative model of the self and increased negative affectivity, but alexithymia was an additional predictor of symptom reporting in individuals with fearful attachment. This difference is thought to be linked to the model of others developed in early interactions with caregivers (Wearden et al. 2005).

For women, childhood trauma influences adult levels of somatization by fostering insecure adult attachment (Waldinger et al. 2006). Families of pseudoseizure subjects are more troubled and may unwittingly contribute to the symptom through family distress, criticism, and tendencies to somatize (Wood et al. 1998). Many patients with somatization disorder are raised in an emotionally cold, distant, and unsupportive family environment characterized by chronic emotional and physical abuse (Brown et al. 2005). In a large female sample, patients with preoccupied and fearful attachments had the highest symptom reporting; however, they were in the opposite ends of healthcare utilization spectrum, i.e. patients with fearful attachment had the lowest healthcare costs (Ciechanowski et al. 2002).

Recent studies document that childhood trauma and dysfunctional attachment may underline the syndrome entitled borderline personality disorder in DSM-IV (American Psychiatric Association 1994); i.e. emotionally unstable personality as its equivalent in ICD-10 (World Health Organization 1992). In fact, there is a large overlap between dissociative disorders and borderline phenomena in clinical and non-clinical populations (Şar et al. 2003, 2006) and many of these subjects have also multiple somatoform symptoms (Saxe et al. 1994; Hudziak et al. 1996). Both dissociative and borderline phenomena are reported to be more common among women then men (Akyüz et al. 1999; Şar et al. 2003, 2006). Curiously, this gender difference is more prominent in clinical settings than in the community (Tutkun et al. 1998). Differences in trauma history, health-seeking behaviour, and symptomatology seem to be responsible for the preponderance of women in clinical settings with this condition including cultural factors (Lewis-Fernández et al. 2007; Martínez-Taboas et al. 2009).

Evidence from several studies demonstrates that patients with pseudoneurological symptoms often experience other MUS. Mace and Trimble (1996) followed-up a group of pseudoneurological patients and found that 64% met criteria for somatization disorder ten years later, even though only 4% received that diagnosis at the outset. Similarly, patients with large numbers of MUS across multiple bodily systems had pseudoneurological complaints as their predominant symptoms (Swartz et al. 1986). Patients with pseudoneurological symptoms have numerous symptoms encompassing multiple systems (Gara et al. 1998).

Patients with pseudoneurological symptoms have overall psychiatric symptom scores close to those of the general psychiatric patients, suggesting high general psychiatric comorbidity (Spitzer et al. 1999). In a two-year follow-up, 89.5% of patients with pseudoneurological symptoms had at least one other psychiatric diagnosis (Şar et al. 2004). In a primary health care centre in Turkey, conversion symptoms were more frequently observed among subjects who had an ICD-10 (World Health Organization 1992) diagnosis depression, generalized anxiety disorder, and neurasthenia being the most prevalent psychiatric disorders (Sagduyu et al. 1997). In the community, the conversion-symptom group had significantly higher comorbidity for lifetime and current major depression, dissociative disorders, and borderline personality disorder than the non-conversion group (Şar et al. 2009). They also reported more suicide attempts and self-mutilation. These features were significantly more prominent in the subgroup with somatization disorder than the conversion disorder group, highlighting a more severe clinical condition.

In an effort to develop a strictly medical model of psychiatric disorders, the so-called Saint Louis school, a research group from Washington University, St. Louis, adopted the earlier work of French physician Pierre Briquet and redefined hysteria (Briquet’s syndrome) as a chronic disorder with multiple somatic complaints, a precursor of today’s somatization disorder (Hudziak et al. 1996). Researchers following this tradition have also investigated possible genetic links among somatization disorder, antisocial personality disorder, and alcoholism. Although those cases exist, only 10.5% of the participants with a conversion symptom had a DSM-IV somatization disorder in an epidemiological study (Şar et al. 2009). Thus, for a majority of subjects, somatoform symptoms are not part of a fully developed somatization disorder or they may coexist with another psychiatric disorder. Conversion group reported a higher frequency of childhood trauma than non-conversion subjects and the rate of childhood trauma was highest in the somatization disorder group (Şar et al. 2009).

Among patients with a dissociative disorder, alongside being an indicator of general severity of the disorder, somatization disorder was also a predictor of suicidal ideation (Öztürk and Şar 2008).

Among patients with conversion disorder, a concurrent dissociative disorder predicts higher psychiatric comorbidity more generally, including somatization disorder, dysthymic disorder, major depression, borderline personality disorder, self-destructive behaviour, suicide attempts, and childhood traumas (Şar et al. 2004). In a group of patients with irritable bowel syndrome, the abused group had substance abuse, dysthymia, and generalized anxiety disorder more frequently than the non-abused patients (Blanchard et al. 2004). Some patients with conversion and dissociative disorders may even decompensate in a dissociative psychotic breakdown when in crisis due to trauma-related intrapsychic factors, interpersonal conflicts, or environmental stress (Şar and Öztürk, 2008, 2009).

Childhood trauma is usually correlated with higher psychiatric comorbidity in many clinical samples (Şar and Ross 2006). Thus, in consideration of this phenomenon, Ross (2007) proposed a trauma model of psychopathology covering several diagnostic categories such as dissociative disorders, somatoform disorders, borderline personality disorder, eating disorders, substance abuse, and even a trauma-related dissociative subtype of schizophrenia. Beside a history of developmental traumas, these patients usually have suicidality, self-mutilative behaviour, dissociative experiences, and a high number of descriptive psychiatric comorbidity in common, leading to a challenge for current psychiatric nosology and classification (Zoroglu et al. 2003; Akyüz et al. 2005; Ross 2007). Patients who fit to this model are less suitable to respond to biological treatment modalities while they usually benefit from psychotherapeutic intervention. These patients remain treatment-resistant for a long time and have complications added if their needs are not handled by mental health delivery system appropriately.

Data do not support the view that various somatoform syndromes are distinct entities (Nimnuan et al. 2001). Thus, a dimensional classification rather than defining diverse syndromes has been proposed (Wessely et al. 1999). We conclude that MUS may be part of a larger complex of psychopathology with temporary predominance of somatization disorder, major depression, dissociative disorder, PSTD, or any combination of them. Beside a broad range of psychiatric comorbidity, episodes of major depression and suicide attempts may be complications throughout the natural course of this process if there is a lack of appropriate psychiatric or psychotherapeutic treatment in particular. It is noteworthy that, in one screening study, only 24.5% of women with a conversion symptom had received psychiatric treatment (Şar et al. 2009). Although most adolescents with somatoform disorders are psychosocially impaired, only a small proportion of them receive treatment (Essau et al. 1999). Thus, the majority of the cases in the community remain unrecognized and untreated except for visits to emergency psychiatry wards when in a crisis situation (Şar and Koyuncu et al. 2007). Given the subjects’ reports of substantial childhood adversity, high psychiatric comorbidity, and chronicity, we conclude that MUS warrant a multidimensional treatment strategy. A full investigation on reasons of preponderance of MUS among women exceeds the boundaries of this study; however, a gender-sensitive approach is warranted while considering this reality with a long past in the history of mental health.