Guest Editorial
Somatization, Hysteria, or Incompletely Explained Symptoms?
Harold Merskey, DM, FRCP, FRCPC, FRCPsych1
In this month’s In Review section, all the contributors—Dr François Mai (1), Dr Laurence Kirmayer and colleagues (2), and I—wrestle with the seemingly intractable and endlessly interesting topic of body–mind relations. In the first review article, Dr Mai lays out the justification for a diagnostic category of somatization disorder. He recognizes that the standard monistic approach that accepts the unity of mind and body can easily be misunderstood. In particular, while we may agree that the phenomenology of a complaint such as the experience of pain cannot be split into organic and psychological components, we must nevertheless determine whenever possible how much a patient’s complaint derives from identifiable or probable physical causes and how much it derives from, or is influenced by, psychosocial factors. To assess diagnosis, causes, and treatments, both types of etiologic formulation have to be qualified and also quantified, if only very broadly.
As Dr Mai indicates, the notion of somatizing or somatization has a peculiar origin in the free translation of a highly questionable concept, organspräche, which we may understand as speaking or symbolizing a problem through some constituent of the body. This speculative idea deserves extra-severe questioning on its own. In the notion of somatizing, a dubious popular psychiatric thought has been blended with the practice that psychiatrists have introduced of defining a condition in terms of hard data. The tight criteria for somatization disorder were originally introduced to circumscribe a particular group of patients who could be isolated for prognostic purposes and other research (3). Although these criteria deliberately did not include all the items that had been labelled as hysteria, the original intent was soon subverted. Guze changed the label to Briquet’s syndrome (4), perhaps hoping to promote its acceptance by associating it with the extensive empirical case material of Pierre Briquet (5), but the DSM-III took over the category and labelled it somatization disorder. So far so good, perhaps, although neither Briquet’s syndrome nor somatization disorder quite describe what Briquet reported (6).
The DSM-III maintains the understanding that somatization disorder is somehow linked with other labels related to the psychological causation of somatic symptoms. These include conversion disorder, psychogenic pain disorder, hypochondriasis, and atypical somatoform disorder, grouped under a general heading of “Somatoform Disorders,” which were matched with another group of conditions identified as “Dissociative Disorders.” Notwithstanding a serious effort in the DSM-III to treat these conditions empirically as part of an atheoretical system, several of them quickly reverted to type in medical practice, where they were seen as based on repression and emotional conflict.
The criteria for somatization disorder were changed substantially in the DSM-IV. The group was also sufficiently unstable that the term psychogenic pain disorder as such was ultimately abandoned and replaced with the term pain disorder. Current evidence suggests that pain disorder is a category that should rarely, if ever, be used (7). Meanwhile, it has also been argued that the term somatizing has multiple uses and meanings that minimize its value (8).
Never mind all that. Forget the theory, as the DSM-III really tried to do, and focus on the phenomena. With regard to this approach, Dr Mai has carefully outlined the criteria and uses of a category that by now corresponds to much of what psychiatrists also call medically unexplained symptoms and that has been further explored by Dr Kirmayer and colleagues (2). Many practitioners tend to diagnose somatization disorder, and likewise pain disorder, without applying the serious restrictions that are supposed to be observed. Mai, of course, does not permit such a solecism, and after refining his patient group according to the DSM-IV diagnostic criteria, which are essentially those of the ICD-10 as well, he is left with a group for whom he recommends cognitive-behavioural therapy (CBT) (1). Alternatively, if it seems that CBT is less suitable for the patient, supportive psychotherapy remains. In the end, he identifies a practical method to manage an important patient group.
Dr Kirmayer and colleagues treat the broader issue of unexplained symptoms at large. By starting with medically unexplained symptoms, they are able to sidestep some of the issues that Mai has resolved and directly study symptoms in the broad physical, psychological, and social context. In doing so, they also look at the large group of patients who present to practitioners in primary care—notably, up to 30% of all patients. Like Mai, they argue that current psychiatric theories are inadequate for these patients, stating that
Psychophysiological and sociopsychological models provide plausible medical explanations for most common somatic symptoms. Psychological explanations are often not communicated effectively, do not address patient concerns, and may lead patients to reject treatment or referral because of potential stigma (2, p 663).
As they have earlier shown, the group that they study includes many whose symptoms can be linked to anxiety and depression and others whose responses are best managed in terms of their psychological condition or social context, or both. They emphasize the recent literature to the effect that psychological issues are commonly found, are known to the patient, are not unconscious, and are treatable. On this basis, they formally articulate the view that most such patients give clear cues about important psychosocial issues and do not hide them from interested physicians as long as these physicians do not confine their interests to a limited, physical-only approach. They reject the common dismissive attitude that patients push for inappropriate investigations and that investigations somehow make patients medically dependent.
These discussions of various patient groups left me wondering about finding a better term than “medically unexplained symptoms.” The phrase implies that—perish the thought— psychology is not part of medicine. Hippocrates would presumably have disapproved. As an alternative, I thought of “physically unexplained symptoms,” but that would not provide an attractive acronym. Perhaps “incompletely explained somatic symptoms” might be fairly acceptable. In fact, almost any polite term is acceptable if it describes attempts to treat pain and discomfort and to remove distress without pejorative implications concerning patient behaviour.
In one field, we have moved much closer to understanding that the great majority of clinical cases have organic origins: in referral practices dealing with chronic pain, the largest number of patients do present with significant physical contributions to their complaints. This is readily understood if we recognize the abundant current evidence indicating that fibromyalgia (FM) is a physical disorder (9,10) and that musculoskeletal symptoms previously considered to be owing to tension or to conversion disorder are far better explained by conditions such as facet joint damage or internal disk disruption (11,12).
Chronic fatigue, whether seen as part of a syndrome or not, may be much harder to elucidate than FM. It is clearly associated with depression and loss of energy but may be insidiously present with many independent physical phenomena. These can be puzzling, particularly if they have affected the nervous system. Likewise dizziness, another commonly unexplained symptom, presents different demands for investigating and ruling out immediately recognizable and treatable physical disorders. I offer these as examples of unexplained symptoms wherein one can make a significant mistake by assuming that the explanation is psychogenic. With regard to patients in pain, we see more and more that the so-called psychogenic explanation does not work but that, as Kirmayer and colleagues show, pain symptoms can nevertheless not only cause suffering and physical disability but also be affected by social and psychological influences (2). It is hard to guess at what we might think in future were a “fatigue marker” to be found and measurable in practice.
Finally, we should note that many symptoms are not explained because for economic and practical reasons they are simply not fully investigated. They come and they go; most people have some sort of daily or weekly complaints, whether of feeling faint, of minor weakness, of occasional nausea, of overfullness, or of transient pains. Some time ago, a family practice survey showed that only 3% of all symptoms encountered on a daily basis were reported to family practitioners (13). “Noise” in the form of transient symptoms that have not been fully investigated provides a huge background out of which incompletely explained somatic symptoms may emerge. Usually they are not explained because it is not worthwhile or feasible for anybody to spend the time and effort involved in tracking down the cause of a minor dull headache, a transient constipation, or a brief episode of air-swallowing. The large number of somatic symptoms that Mai and Kirmayer and colleagues recognize and that are found in the general community seem to be the tip of the iceberg of normal transient changes in comfort and discomfort existing in any population. Medicine will never deal with everything that happens in our bodies, only with selected symptoms or sets of symptoms. This background of selection is inherent from the moment of first consultation, whether with relatives, friends, acquaintances, or primary care practitioners.
Most physicians find it easy to understand that physical symptoms can be modified by emotional status. We also need to understand that for solid practical reasons many bodily symptoms with physical origins often go undiagnosed and should not be classed as psychological without specific evidence. The sort of evidence that is needed can be appreciated from this section’s articles.
Offering a third formulation along with the others so far given, I suggest that most pain in the clinic is physical in origin but that sometimes it is modified by emotion, as we might expect.
References
1. Mai F. Somatization disorder: a practical review. Can J Psychiatry 2004;49:652– 62.
2. Kirmayer LJ, Groleau D, Looper KJ, Domince Dao M. Explaining medically unexplained symptoms. Can J Psychiatry 2004;49:663–72.
3. Cohen ME, Robins E, Purtell JJ, Altmann MW, Reid DE. Excessive surgery in hysteria: study of surgical procedures in 50 women with hysteria and 190 controls. JAMA 1953;151:977–86.
4. Guze SB. The role of follow-up studies: their contribution to diagnostic classification as applied to hysteria. Semin Psychiatry 1970;2:392–402.
5. Briquet P. Traité clinique et thérapeutique de l’hystérie. Paris: JB Baillièrre et Fils; 1859.
6. Mai F, Merskey H. Briquet’s “treatise on hysteria”: a synopsis and commentary. Arch Gen Psychiatry 1980;26:57–63.
7. Merskey H. Pain disorder, hysteria or somatization? Pain Res Manag 2004;9:67–73.
8. Merskey H. Beware somatization. Eur J Pain 2001;4:3–4.
9. Bennett RM. Fibromyalgia. In: Wall PD, Melzack R, ediors. Textbook of pain. 4th ed. Edinburgh (UK): Churchill Livingstone; 1999. p 579–601.
10. Russell IJ. Fibromyalgia. In: Loeser JD, Butler SH, Chapman CR, Turk DC, editors. Bonica’s management of pain. 3rd ed. Philadelphia (PA): Lippincott, Williams & Wilkins; 2001. p 543–56.
11. Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. New Engl J Med 1996;335:1721–6.
12. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine,1995;20:1878–83.
13. Banks MH, Beresford SHZ, Morrell DC, Waller JJ, Watkins CJ. Factors influencing demand for primary medical care in women aged 20-40 years; a preliminary report. Int J Epidemiol 1975;4:189–255.
Author
1. Emeritus Professor, Department of Psychiatry, University of Western Ontario, London, Ontario.
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