Somatization and conversion disorders: comorbidity and demographics at presentation Tomasson K, Kent D, Coryell W. Somatization and conversion disorders: comorbidity and demographics at presentation. Acta Psychiatr Scand 1991: 84: 288-293. Although somatization disorder and conversion disorder are linked in DSM-111 and DSM-111-R, they have very different histories. To directly compare these disorders, we reviewed the records accrued for 2 years at a large medical center and identified 65 somatization disorder patients and 5 1 conversion disorder patients. They differed substantially. The large majority (78%) of conversion disorder patients and nearly all (95%) of the somatization disorder patients were women. Ages at onset occurred throughout the life span among conversion disorder patients but mostly before the age of 21 among the somatization disorder patients. Somatization disorder patients were more likely to have had a history of depression, attempted suicide, panic disorder and divorce.
The Egyptians in 1900 B.C. (1) recognized the existence of a disorder in which physical symptoms existed in the absence of demonstrable organic pathology. The Greeks at the time of Corpus Hippocraticum also acknowledged this condition and the enduring term hysteria stems from them. In the ninth century, the medical school at Salerno (2) taught that hysteria was a physical disorder; during the Middle Ages hysteria was associated with evil spirits and the devil (3), and during the 19th century Briquet, Reynolds and Charcot implicated the central nervous system and psychological factors in the origins of this disorder (1,4). Much more recently, Purtell(5) summarized case descriptions from Briquet’s work. Gatfield & Guze (4) used them to form operational criteria that emphasized an early onset (before age 35) of multiple complaints (25 or more), involvement of diverse organ systems, dramatic descriptions of symptoms and excessive use of medical care. With these criteria they found that the clinical picture was stable in 80-90% of the patients over 6-8 years. DSM-ICI(6) and later DSM-111-R (7) used a simplified version of these criteria and abandoned the term “Briquet’s syndrome” in favor of “somatization disorder”. The term conversion was first used by Freud to refer to the substitution of a somatic symptom for a repressed idea (1). According to this view (8), the conversion of a mental conflict into physical and mental symptoms involves primary gain and unconscious motivation. Conversion was not recognized as a separate disorder from hysteria until the publication of DSM-111. However, DSM-111 and then 288
K. Tomasson, D. Kent, W. Coryell Department of Psychiatry, College of Medicine, University of Iowa, Iowa City, USA
Key words: somatoform; somatization; conversion
Kristinn Tornasson M.D., Department of Psychiatry, National University Hospital, 10 1 Reykjavik, Iceland Accepted for publication April 30, 199 1
later DSM-111-R clearly separated these disorders and provided criteria for conversion disorder based closely on Freudian concepts. The validity of both disorders has been questioned (1, 9-1 1). However, data from epidemiological surveys (12), studies on utilization of health services (13) as well as family history and follow-up studies (14-17) have supported the validity of somatization disorder. There is little equivalent data for the validity of conversion disorder, nor has this disorder been directly compared with somatization disorder despite the historically nosological association between them. This study draws such a comparison based on demographics and associated psychopathology. We expected the disorders to differ on these variables, but we were unclear as to the direction and magnitude of such difference. Material and methods
One of the authors (K.T.) reviewed the charts of all patients with a diagnosis of conversion disorder, somatization disorder, hypochondriasis, hysteria unspecified, histrionic personality disorder and factitious disorder from 1984 to 1986 (index visit) at the University of Iowa Hospitals and Clinics. Charts from both inpatient and outpatient and from every clinical service, including psychiatry, were surveyed. The material reviewed included all doctor’s notes, consultations, laboratory and radiology results and nursing notes, as well as outside records dated on or before the outpatient visit or inpatient discharge at which the index diagnosis was first made. This re-
Somatization and conversion
view recorded basic demographic information and applied DSM-111 criteria (6) for somatization disorder (Briquet’s syndrome), conversion disorder, and major depressive disorder and panic disorder (we suspended the criteria precluding a co-diagnosis of somatization disorder and panic disorder). We elected to use DSM-111 criteria, as those were the criteria used when the patients were seen. We noted any history of delusions or hallucinations, any alcohol or substance abuse, and the total number of medical diagnoses given at the index visit. Only medical diagnoses supported by physical, laboratory or radiological evidence were noted. DSM-I11 conversion disorder requires that the conversion symptom be preceded by a stressful life event, allow the patient to avoid certain circumstances or enable the patient to receive support that otherwise would not be forthcoming. We noted the presence or absence of each of these factors. We further subdivided life events as follows: 1) loss - any negative event that had resulted or may have resulted in a permanent loss for the patient, such as loss of employment, divorce, death of a relative or spouse and sudden or anticipated loss of health; 2) personal - any event that pertained to the patient’s family or close friends; 3) health - any event related to the patient’s health; 4) work - any event at work or directly pertaining to the patient’s work or employment; and 5) miscellaneous. An event could fall into only 1 category or any number of them. Results
Of 99,391 male and 120,915 female patients seen during the index period, only 250 had been given any of the diagnoses surveyed. Of these, we identified 5 1 patients with conversion disorder and 65 with somatization disorder. Included among these were 12 patients who met criteria for both conversion disorder and somatization disorder and, in accordance with DSM-111, they were given the diagnosis of somatization disorder rather than conversion disorder. The remaining 134 patients did not meet criteria for either disorder for a variety of reasons. Within this latter group were 4 with symptoms under voluntary control and 15 whose presenting symptom had a medical explanation; 9 patients had complaints limited to pain and sexual problems, and 119 did not have a preceding life event nor did their symptoms allow them to avoid certain circumstances or to obtain support that was not otherwise forthcoming. Furthermore, of these 119 patients who did not meet criteria for either disorder, 41 had a chart diagnosis of somatization disorder and 23 a chart diagnosis of
conversion disorder. We measured the diagnostic concordance between our diagnoses and the chart diagnoses (kappa). For alcohol abuse, somatization disorder and conversion disorder, kappa was moderate (0.40, 0.43 and 0.49) but for major depressive and panic disorder it was higher (0.81 and 0.86). Women were overrepresented in both groups but this was particularly so among the somatization disorder patients (Table 1). Despite a similar mean age, a substantially larger portion of conversion disorder patients (22%) were under 20 years of age than were somatization disorder patients (2 %) (Fig. 1). On the other hand, the majority of somatization patients had onset when they were less than 20 (Fig. 2) even though the criteria only required onset under 30 years. Conversion disorder patients had onset distributed across the entire age spectrum. Patients with somatization disorder were nearly twice as likely as patients with conversion disorder to have been divorced. These groups did not differ by employment or educational status. Disability for physical reasons was also common for both somatization disorder (19%) and conversion disorder patients (22%). In contrast, only 6% of the 134 patients who did not meet criteria for either disorder were on disability for physical reasons (x’ = 9.5, df = 2, P < 0.01). Disability for mental reasons was more common among the somatization disorder patients (NS). Nearly three-quarters (71 %) of the conversion disorder patients presented with a central nervous system (CNS) complaint (Table 2). Mental main complaints were rare among the conversion disorder patients but quite common (25%) among the somatization patients. Of the 15 conversion disorder patients with a non-CNS main complaint, 7 had another complaint of an unexplained CNS symptom. Two of the 8 remaining patients had pseudocyesis
Table 1. Demographics of the chart review sample Conversion disorder n=51 Sex (% female) Age in years mean (range) - at index - at first unexplained symptom Education (% 12 years or less) Married (%) Ever divorced (%) Unemployed (%) Disability, physical reasons (%) Disability, mental reasons (%) Employed/student (%)
* X2=6.22,d.f.
Somatization disorder n=65
78
95*
37 (9-701 30 (3-64) 80 48 31 37 22 2 28
41 (15-74) 17 (5-30)*** 73 48 57** 40 19 11 29
= 1, P 60 years
Somatization disorder
35 30 25 20 O!O
15 10
5 0
i
i
110
-15
-20
-25
-30
-35
-40
-45
-50
-55
-60
>60 years
Fig. 2. Age at first medically unexplained symptom
and 6 had difficulty swallowing or lump in the throat as main complaints. These group differences in main complaints were further reflected in the clinics attended; 41 % of conversion disorder patients vs 18% of the somatization disorder patients presented to a neurology or neurosurgery clinic and 12% and 31%, respectively, 290
presented to the psychiatric clinic. Neither group was significantly overrepresented in the other services. At index, 61 % of the conversion and 82% of the somatization disorder patients were inpatients. The most common specific main complaints for conversion disorder patients were fits (24%), paralysis (10%) and lump in the throat (8%). For the
Somatization and conversion Table 2. Main complaints according to anatomical and physiological systems
-~
Conversion disorder n=51 %
Somatization disorder n= 65 %
71** 0 12 0 0 8 10
22 14 17 6 3 25* 14
~
Central nervous system Cardiopulmonary Gastrointestinal Genitourinary Musculoskeletal Mental Request for a test or procedure
*f=5.04, d.f.=l, P < 0 . 0 5 ; * * ~ ~ = 2 6 . 1d.f.=l, , P
The Egyptians in 1900 B.C. (1) recognized the existence of a disorder in which physical symptoms existed in the absence of demonstrable organic pathology. The Greeks at the time of Corpus Hippocraticum also acknowledged this condition and the enduring term hysteria stems from them. In the ninth century, the medical school at Salerno (2) taught that hysteria was a physical disorder; during the Middle Ages hysteria was associated with evil spirits and the devil (3), and during the 19th century Briquet, Reynolds and Charcot implicated the central nervous system and psychological factors in the origins of this disorder (1,4). Much more recently, Purtell(5) summarized case descriptions from Briquet’s work. Gatfield & Guze (4) used them to form operational criteria that emphasized an early onset (before age 35) of multiple complaints (25 or more), involvement of diverse organ systems, dramatic descriptions of symptoms and excessive use of medical care. With these criteria they found that the clinical picture was stable in 80-90% of the patients over 6-8 years. DSM-ICI(6) and later DSM-111-R (7) used a simplified version of these criteria and abandoned the term “Briquet’s syndrome” in favor of “somatization disorder”. The term conversion was first used by Freud to refer to the substitution of a somatic symptom for a repressed idea (1). According to this view (8), the conversion of a mental conflict into physical and mental symptoms involves primary gain and unconscious motivation. Conversion was not recognized as a separate disorder from hysteria until the publication of DSM-111. However, DSM-111 and then 288
K. Tomasson, D. Kent, W. Coryell Department of Psychiatry, College of Medicine, University of Iowa, Iowa City, USA
Key words: somatoform; somatization; conversion
Kristinn Tornasson M.D., Department of Psychiatry, National University Hospital, 10 1 Reykjavik, Iceland Accepted for publication April 30, 199 1
later DSM-111-R clearly separated these disorders and provided criteria for conversion disorder based closely on Freudian concepts. The validity of both disorders has been questioned (1, 9-1 1). However, data from epidemiological surveys (12), studies on utilization of health services (13) as well as family history and follow-up studies (14-17) have supported the validity of somatization disorder. There is little equivalent data for the validity of conversion disorder, nor has this disorder been directly compared with somatization disorder despite the historically nosological association between them. This study draws such a comparison based on demographics and associated psychopathology. We expected the disorders to differ on these variables, but we were unclear as to the direction and magnitude of such difference. Material and methods
One of the authors (K.T.) reviewed the charts of all patients with a diagnosis of conversion disorder, somatization disorder, hypochondriasis, hysteria unspecified, histrionic personality disorder and factitious disorder from 1984 to 1986 (index visit) at the University of Iowa Hospitals and Clinics. Charts from both inpatient and outpatient and from every clinical service, including psychiatry, were surveyed. The material reviewed included all doctor’s notes, consultations, laboratory and radiology results and nursing notes, as well as outside records dated on or before the outpatient visit or inpatient discharge at which the index diagnosis was first made. This re-
Somatization and conversion
view recorded basic demographic information and applied DSM-111 criteria (6) for somatization disorder (Briquet’s syndrome), conversion disorder, and major depressive disorder and panic disorder (we suspended the criteria precluding a co-diagnosis of somatization disorder and panic disorder). We elected to use DSM-111 criteria, as those were the criteria used when the patients were seen. We noted any history of delusions or hallucinations, any alcohol or substance abuse, and the total number of medical diagnoses given at the index visit. Only medical diagnoses supported by physical, laboratory or radiological evidence were noted. DSM-I11 conversion disorder requires that the conversion symptom be preceded by a stressful life event, allow the patient to avoid certain circumstances or enable the patient to receive support that otherwise would not be forthcoming. We noted the presence or absence of each of these factors. We further subdivided life events as follows: 1) loss - any negative event that had resulted or may have resulted in a permanent loss for the patient, such as loss of employment, divorce, death of a relative or spouse and sudden or anticipated loss of health; 2) personal - any event that pertained to the patient’s family or close friends; 3) health - any event related to the patient’s health; 4) work - any event at work or directly pertaining to the patient’s work or employment; and 5) miscellaneous. An event could fall into only 1 category or any number of them. Results
Of 99,391 male and 120,915 female patients seen during the index period, only 250 had been given any of the diagnoses surveyed. Of these, we identified 5 1 patients with conversion disorder and 65 with somatization disorder. Included among these were 12 patients who met criteria for both conversion disorder and somatization disorder and, in accordance with DSM-111, they were given the diagnosis of somatization disorder rather than conversion disorder. The remaining 134 patients did not meet criteria for either disorder for a variety of reasons. Within this latter group were 4 with symptoms under voluntary control and 15 whose presenting symptom had a medical explanation; 9 patients had complaints limited to pain and sexual problems, and 119 did not have a preceding life event nor did their symptoms allow them to avoid certain circumstances or to obtain support that was not otherwise forthcoming. Furthermore, of these 119 patients who did not meet criteria for either disorder, 41 had a chart diagnosis of somatization disorder and 23 a chart diagnosis of
conversion disorder. We measured the diagnostic concordance between our diagnoses and the chart diagnoses (kappa). For alcohol abuse, somatization disorder and conversion disorder, kappa was moderate (0.40, 0.43 and 0.49) but for major depressive and panic disorder it was higher (0.81 and 0.86). Women were overrepresented in both groups but this was particularly so among the somatization disorder patients (Table 1). Despite a similar mean age, a substantially larger portion of conversion disorder patients (22%) were under 20 years of age than were somatization disorder patients (2 %) (Fig. 1). On the other hand, the majority of somatization patients had onset when they were less than 20 (Fig. 2) even though the criteria only required onset under 30 years. Conversion disorder patients had onset distributed across the entire age spectrum. Patients with somatization disorder were nearly twice as likely as patients with conversion disorder to have been divorced. These groups did not differ by employment or educational status. Disability for physical reasons was also common for both somatization disorder (19%) and conversion disorder patients (22%). In contrast, only 6% of the 134 patients who did not meet criteria for either disorder were on disability for physical reasons (x’ = 9.5, df = 2, P < 0.01). Disability for mental reasons was more common among the somatization disorder patients (NS). Nearly three-quarters (71 %) of the conversion disorder patients presented with a central nervous system (CNS) complaint (Table 2). Mental main complaints were rare among the conversion disorder patients but quite common (25%) among the somatization patients. Of the 15 conversion disorder patients with a non-CNS main complaint, 7 had another complaint of an unexplained CNS symptom. Two of the 8 remaining patients had pseudocyesis
Table 1. Demographics of the chart review sample Conversion disorder n=51 Sex (% female) Age in years mean (range) - at index - at first unexplained symptom Education (% 12 years or less) Married (%) Ever divorced (%) Unemployed (%) Disability, physical reasons (%) Disability, mental reasons (%) Employed/student (%)
* X2=6.22,d.f.
Somatization disorder n=65
78
95*
37 (9-701 30 (3-64) 80 48 31 37 22 2 28
41 (15-74) 17 (5-30)*** 73 48 57** 40 19 11 29
= 1, P 60 years
Somatization disorder
35 30 25 20 O!O
15 10
5 0
i
i
110
-15
-20
-25
-30
-35
-40
-45
-50
-55
-60
>60 years
Fig. 2. Age at first medically unexplained symptom
and 6 had difficulty swallowing or lump in the throat as main complaints. These group differences in main complaints were further reflected in the clinics attended; 41 % of conversion disorder patients vs 18% of the somatization disorder patients presented to a neurology or neurosurgery clinic and 12% and 31%, respectively, 290
presented to the psychiatric clinic. Neither group was significantly overrepresented in the other services. At index, 61 % of the conversion and 82% of the somatization disorder patients were inpatients. The most common specific main complaints for conversion disorder patients were fits (24%), paralysis (10%) and lump in the throat (8%). For the
Somatization and conversion Table 2. Main complaints according to anatomical and physiological systems
-~
Conversion disorder n=51 %
Somatization disorder n= 65 %
71** 0 12 0 0 8 10
22 14 17 6 3 25* 14
~
Central nervous system Cardiopulmonary Gastrointestinal Genitourinary Musculoskeletal Mental Request for a test or procedure
*f=5.04, d.f.=l, P < 0 . 0 5 ; * * ~ ~ = 2 6 . 1d.f.=l, , P
