The Comorbidity of DSM-III-R Personality Disorders in Somatization Disorder Kathryn M. Rost, Ph.D., Richard N. Akins, M.D., Frank W. Brown, M.D., and G. Richard Smith, M.D.
Abstract: In order to understand psychiatric factors that complicate the medical management of somatizing patients, 94 subjects with known somatization disorder (SD) were evaluated for 13 personality disorders with the Structured Clinical Interview for DSM-111-R Personality Disorders. Referred from multiple primary care settings, the patient sample was predominantly female (85%), married (67%), high school graduates (64%)‘ and had a mean age of 43. Structured interviews documented that 23.4% of SD patients had one personality disorder, and 37.2% had two or more disorders. The four most frequently identified personality disorders were avoidance 26.7%, paranoia 21.3%, self-defeating: 19.1%, and obsessivecompulsive 17.1%. Interestingly histrionic personality disorder was identified in only 12.8% of the sample and antisocial personality disorder in 7.4%. In making the diagnosis of SD, health care providers need to avoid the common clinical impression that histrionic behavior often accompanies the disorder. Further research with SD patients is needed to examine the relationship of co-occurring personality disorders to symytom recurrence, health care utilization, and readiness for psychiatric referral.
Introduction The diagnostic complexity and lenge of treating patients with order (SD) extends much further multiple, unexplained somatic
therapeutic chalsomatization disthan their chronic, complaints. Pre-
From the Departments of Psychiatry (KMR, RNA, GRS) and Medicine (GRS), University of Arkansas for Medical Sciences, and the VA HSR&D Field Program for Mental Health (GRS), Little Rock, Arkansas; and the Department of Psychiatry, Emory University, Atlanta, Georgia (FWB). Address reprint requests to: Kathryn Rost, Ph.D., University of Arkansas for Medical Sciences, Department of PsychiatrySlot 554, 4301 W. Markham Street, Little Rock, AR 72205.
322 ISSN 0163-8343/92/$5.00
vious work has demonstrated that SD patients have substantial comorbid Axis I diagnoses. Depressive disorders have been diagnosed in 55%-94% of SD patients, panic disorder in 26%-45% of SD patients, and alcohol abuse or dependence in 17%-31% of SD patients [l-4]. However, what many clinicians find most striking about SD patients is their Axis II psychopathology. Experienced clinicians often find themselves managing the characterological problems of SD patients as often as managing the somatization itself. This task is complicated by the fact that physicians’ impressions about common personality disorders in SD patients are different than those described in the literature. This study reports the distribution of DSM-III-R personality disorders in a large cohort of SD patients from a primary care setting. Given its clinical importance, relatively little is known about the prevalence of Axis II disorders in these difficult-to-manage patients. Only histrionic and antisocial personality disorder have been extensively investigated in SD patients. Histrionic personality disorder has been frequently studied because hysteria is noted to be the forerunner of modern-day SD. In three studies of SD patients in psychiatric settings, estimates of co-occurring histrionic personality disorder range from 54.1% to 81.8% [5-71. A fourth investigation estimated the co-occurrence of histrionic personality disorder in psychiatric patients with somatoform disorders to be only 7.4% [a]. Antisocial personality disorder (ASP) has been studied because its co-occurrence with SD has important implications for psychiatric nosology. Cloninger et al. [9] have proposed comGo~rnlHuspir~IPsycl~intry14, 322-326, 1992 0 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Personality
mon etiologic and pathogenic factors for ASP in men and SD in women. When psychiatric outpatients with SD are considered, rates of co-occurring ASP range from 3.6% to 16.770, with higher rates among psychiatric patients described as refractory (53.1%)) [6], inpatients (25.0%) [3], and felons studies demonstrate (63.0%) [lo]. C om p arative that the prevalence of ASP in men with SD was 3.5 times greater than in women with SD [ll]. Studies of personality disorders in patients with multiple unexplained physical complaints, presumably including some patients with SD, have been reported for only three cohorts. Among 14 psychiatric patients diagnosed with a somatoform disorder, structured interviews indicated that 64% had at least one personality disorder. The most frequently identified personality disorders were avoidant, dependent, borderline, and compulsive [12]. In a second study of 27 psychiatric patients with a somatoform disorder, psychiatrists diagnosed only 30% of patients with a personality disorder; dependent and mixed disorders were the most common IS]. In a third study of 100 patients referred to a consultation-liaison service for evaluation of medically unexplained symptoms, only 4% were diagnosed with a personality disorder. Though this is considerably lower than the other two estimates, only 34% of patients in the cohort received a diagnosis of somatoform disorder [13]. Although they represent the most systematic studies to date of personality disorder in somatoform patients, these studies utilized small sample sizes and produced inconclusive results about the comorbidity of personality disorders and SD. Even if clear trends existed, it is questionable whether the rates of personality disorders in psychiatric patients with somatoform disorders are generalizable to most SD patients who seek treatment primarily in medical settings [4,14]. To address these limitations in the research to date, we designed a study to identify the distribution of all DSM-III-R personality disorders in a large cohort of patients with SD currently in treatment in primary care settings.
Methods This study was conducted in conjunction with a pilot study and a subsequent full-scale investigation of a consultation-liaison intervention to promote cost-effective care for SD patients described at length elsewhere [15]. Patients were recruited from practicing primary care physicians within
Disorder
in Somitization
Disorder
a 30-mile radius of Little Rock, Arkansas and provided informed consent to the investigators. Somatization disorder was diagnosed by semistructured interviews conducted by a research psychiatrist who determined whether patients had a lifetime history of 44 physical symptoms, including the 37 symptoms used to make the diagnosis of somatization disorder. A thorough medical record review was used to identify reported symptoms that were not medically explainable. The research team also administered the Diagnostic Interview Schedule (DIS) [16] and collected information on each subject’s social and surgical history. All subjects were then given the Structured Clinical Interview for Diagnosis of DSM-III-R Personality Disorders (SCID-I’D) [17] by one of three clinicians after the clinician reviewed DIS diagnoses to evaluate whether Axis I psychiatric disorders were influencing responses during the personality disorder interview. With the SCID-I’D, each criterion for 13 DSM-III-R personality disorders was scored for severity to determine whether each disorder was present, subthreshold, or absent. Though we did not have the opportunity to characterize interrater reliability among the three clinicians, the test-retest reliability of the SCID-I’D has proved adequate for the diagnosis of personwith kappas averaging 0.50 at 2ality disorders, week retest.
Results Subjects recruited to the study were 85.1%’ female, 76.8% white, and 67.0% married. In terms of education, 63.8% of the sample were high school graduates or above. Mean age was 43.2 (SD = 10.0). Though 39.4% of the sample had no identifiable personality disorder, 23.4% had one diagnosed personality disorder. Two personality disorders were identified in 13.8% of the sample; three or more disorders were identified in 23.4% of the sample. The prevalence of any personality disorder did not vary for subjects who completed the SCID-I’D before, during, or after the original study’s intervention (x” = 1.42, two tailed p = 0.49). Table 1 illustrates the prevalence of each personality disorder in the sample. The most frequently identified disorders were avoidant 26.7%, paranoid 21.3%, self-defeating 19.170, and obsessive-compulsive 17.0%. Histrionic personality disorder was identified in 12.8% of the sample and antisocial personality disorder represented only 7.4% of the sample. 323
K. M. Rost et al.
Table
1. Frequencies of DSM-III-R personality disorders diagnosed in a sample of somatization disorder patients referred from primary care settings (N = 94) and a sample of general medical patients (N = 87) Frequency of
DSM-III-R personality
disorder (%)
disorder
Avoidant Paranoid Self-defeating Obsessive-compulsive Schizotypal Histrionic Borderline Dependent Passive-aggressive Antisocial Schizoid Narcissistic Not otherwise specified Data describing
general
medical
Frequency of subthreshold
26.7 21.3 19.1 17.0 14.9 12.8 10.6 8.5 8.5 7.4 3.2 3.2 2.2 patients
8.5 17.0 14.9 12.8 11.7 10.6 14.9 12.8 9.6 3.2 5.3 6.4 0.0
Frequency of disorder in general medical patients (%) 2.3 2.3 2.9 6.3 0.6 4.6 3.4 1.7 3.4 1.7 1.1 1.1 -
in this table are from First et al., unpublished.
We were not able to conduct SCID-PD interviews with a comparison sample of non-SD patients, but we can compare the prevalence of personality disorders in our population to the prevalence of personality disorders as determined by the SCID-I’D reported in a general medical population (M. First et al., unpublished data). Personality disorders are 2.5-11.6 times more common in SD patients in our sample than they are in general medical patients, a group that presumably includes some patients with nondiagnosed SD.
Discussion The 61% co-occurrence of personality disorders in 94 primary care SD patients is surprisingly comparable to the findings of the previous study of psychiatric patients with somatoform disorder where structured interviews demonstrated that 64% had at least one personality disorder [12]. These studies suggest that personality disorders deserve considerable clinical attention because they are widespread in SD patients, and represent a notably different spectrum of disorders than the previous literature would suggest. Somatization disorder does not appear to be associated with any one or combination of currently defined personality disorders. Though most studies of psychiatric patients report that over half of all SD patients have histrionic personality disorder, the disorder could be diagnosed in only 12.8% of SD subjects recruited in this study of primary care
324
disorder (%)
patients. Similarly, the 7.4% prevalence of ASP in primary care SD patients is much less than the cooccurrence of ASP in most studies of psychiatric patients with SD. One explanation for this difference is that the acting out associated with antisocial personality and histrionic disorders results in earlier identification of the patient’s psychiatric problems and treatment in the mental health care setting. Instead of dramatic personality disorders (histrionic and ASP), the most common Axis II disorders in this primary care sample were from the anxious or odd cluster. The high prevalence of avoidant personality disorder we found in SD patients is not surprising. The development of symptoms may allow SD patients a ‘legitimate’ reason to avoid a decision or the opportunity to see the physician who may then be manipulated into making a decision that the patient desires to avoid. The high prevalence of paranoid personality disorders in this group reflects the discomfort that many SD patients have with their own feelings. Though paranoid personalities classically deal with this discomfort by attributing their fears to external causes, they may also see their own body as ‘against’ them. It is somewhat of a paradox, however, why SD patients with paranoid personality disorder pursue physicians so adamantly after repeated failure to obtain help from them. It is plausible that this subgroup of patients has a greater frequency of doctor shopping, as they are more likely to see the doctor as an enemy instead of an ally.
Personality
The high prevalence of self-defeating personality disorder in SD patients reflects a deranged selfimage which prevents them from believing that they deserve anything good, including the possibility that they may be healthy rather than defective. The high prevalence of obsessive-compulsive disorder also sheds light on SD patients’ excessive symptoms in the absence of signs of disease. These patients may believe that it is only their hypervigilance that prevents them from becoming sick; thus, they amplify normal physiological variation into discomfort or illness. It appears likely that all these personality disorders contribute to SD patients’ notorious reluctance to discuss psychological issues in their treatment [lS], as clinicians have noted that many of these disorders are often associated with a lack of psychological mindedness. Patients who somatize preferentially seek care in the medical sector [4,14] where primary care physicians and specialists often fail to consider any psychiatric diagnosis in their elusive and expensive search for an organic cause [19]. SD is a relatively infrequent problem in the general population [4], but SD patients represent as many as 5% of patients seen in outpatient medical clinics [20] and 9% of admissions to general medical and surgical services [21]. These findings can help primary care physicians recognize SD patients and anticipate management issues that may emerge in the doctorpatient relationship. As to recognition, SD patients generally will not present in the exaggerated manner characteristic of patients with dramatic personality disorders. Rather, SD patients will present with anxious or odd characteristics. In the doctorpatient interaction, they are less likely to be demanding and more likely to be needy (anxious) or unusual (odd). Management approaches that physicians usually use with patients with dramatic personality disorders will be less effective. Instead, physicians will need to be more supportive and flexible in order to deal effectively with many SD patients. Our characterization of the prevalence of various personality disorders among SD patients is limited by current methodology to diagnose Axis II disorders. We were especially concerned that the presence of an Axis I diagnosis other than SD would confound our measurement of personality disorders, so we systematically informed clinicians of subjects’ Axis I diagnoses before they assessed personality disorders. Analyses in addition to the ones we present in this paper indicate that this methodology resulted in comparable likelihood of per-
Disorder in Somitization
Disorder
sonality disorders in patients with and without an Axis I diagnosis other than SD. Though not conclusive, these results are consistent with the hypothesis that Axis I psychopathology did not substantially confound our measurement of personality disorders. Future research is needed to investigate how personality disorders affect the course and outcome of treatment provided patients with SD in medical settings. Other investigators have found that personality disorders alter patient response to treatment for major depression [22] and panic disorder [23]. Further research is needed to understand the relationship of personality disorders in SD patients to clinically important variables such as frequency of help seeking, functional impairment, health care expenditures, and readiness for psychiatric referral. If particular personality disorders can be linked to poorer outcomes and excessive utilization, clinical interventions targeted to this special group of SD patients can be designed and tested for their cost effectiveness in primary care settings.
References 1. Brown FW, Golding JM, Smith GR: Psychiatric comorbidity in primary care somatization disorder. Psychosom Med 52445-451, 1990 2. Liskow B, Othmer E, Penick EC, DeSouza C, Gabrielli W: Is Briquet’s syndrome a heterogeneous disorder? Am J Psychiatry 143:626-629, 1986 3. Liskow B, Penick EC, Powell BJ, Haefele WF, Campbell JL: Inpatients with Briquet’s syndrome: presence of additional psychiatric syndromes and MMPI results. Compr Psychiatry 27:461-470, 1986 4. Swartz M, Landerman R, George L, Blazer D, Escobar J: Somatization disorder. In Robins LN, Regier D (eds), Psychiatric Disorders In America. New York, Free Press, 1990 5. Kimble R, Williams JG, Agras S: A comparison of two methods of diagnosing hysteria. Am J Psychiatry 132:1197-1199, 1975 6. Lilienfeld SO, VanValkenburg C, Larntz K, Akiskal HS: The relationship of histrionic personality disorder to antisocial personality and somatization disorders. Am J Psychiatry 143:718-722, 1986 7. Morrison J: Histrionic personality disorder in women
325
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8.
9.
10.
11.
12.
13.
14.
326
with somatization disorder. Psychosomatics 30:433437, 1989 Koenigsburg HW, Kaplan RD, Gilmore MM: The relationship between syndrome and personality disorder in DSM-III: experience with 2462 patients. Am J Psychiatry 142:207-212, 1985 Cloninger CR: The link between hysteria and sociopathy: an integrative model of pathogenesis based on clinical, genetic, and neurophysiological observations. In Psychiatric Diagnosis: Exploration of Biological Predictors. New York, Spectrum Publications, 1978, pp 189-218 Cloninger CR, Guze SB: Female criminals: their personal, familial, and social backgrounds. The relation of these to the diagnoses of sociopathy and hysteria. Arch Gen Psychiatry 23:554-558, 1970 Cloninger CR, Martin RL, Guze SB, Clayton I’J: A prospective follow-up and family study of somatization in men and women. Am J Psychiatry 143:873878, 1986 Alnaes R, Torgersen S: The relationship between DSM-III symptom disorders (Axis I) and personality disorders (Axis II) in an outpatient population. Acta Psychiatr Stand (Copenh) 78:485-492, 1988 Slavney PR, Teitelbaum ML: Patients with medically unexplained symptoms: DSM-III diagnoses and demographic characteristics. Gen Hosp Psychiatry 7:21-25, 1985 Escobar JI, Golding JM, Hough RL, Karno M, Burnam MA, Wells KB: Somatization in the community: relationship to disability and use of services. Am J Public Health 77:837-840, 1987
15. Smith GR, Jr, Monson RA, Ray DC: Psychiatric consultation in somatization disorder: a randomized, controlled study. N Engl J Med 314:1407-1413, 1986 16. Woodruff RA, Robins LN, Taibleson M, Reich T, Schwin R, Frost N: A computer-assisted derivation of a screening interview for hysteria. Arch Gen Psychiatry 29:450-454, 1973 17. Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II, Version 1.0). Washington, DC, American Psychiatric Press, 1990 18. Kaplan C, Lipkin M, Jr, Gordon GH: Somatization in primary care: patients with unexplained and vexing medical complaints. J Gen Intern Med 3:177-190, 1988 19. Smith GR, Jr, Monson RA, Ray DC: Patients with multiple unexplained symptoms: patient characteristics, functional health, and health care utilization. Arch Intern Med 146:69-72, 1986 20. deGruy F, Columbia L, Dickinson I’: Somatization disorder in a family practice. J Fam Pratt 25:45-51, 1987 21. deGruy F, Crider J, Hashimi DK, Dickinson I’, Mullins HC, Troncale J: Somatization disorder in a university hospital. J Fam Pratt 25:579-584, 1987 22. Shea MT, Pilkonis PA, Beckham E, et al: Personality disorders and treatment outcome in the NIMH treatment of depression collaborative research program. Am J Psychiatry 147:711-718, 1990 23. Mavissakalian M, Hamann M: DSM-III personality disorder in agoraphobia II: changes with treatment. Compr Psychiatry 28:356-361, 1987
Abstract: In order to understand psychiatric factors that complicate the medical management of somatizing patients, 94 subjects with known somatization disorder (SD) were evaluated for 13 personality disorders with the Structured Clinical Interview for DSM-111-R Personality Disorders. Referred from multiple primary care settings, the patient sample was predominantly female (85%), married (67%), high school graduates (64%)‘ and had a mean age of 43. Structured interviews documented that 23.4% of SD patients had one personality disorder, and 37.2% had two or more disorders. The four most frequently identified personality disorders were avoidance 26.7%, paranoia 21.3%, self-defeating: 19.1%, and obsessivecompulsive 17.1%. Interestingly histrionic personality disorder was identified in only 12.8% of the sample and antisocial personality disorder in 7.4%. In making the diagnosis of SD, health care providers need to avoid the common clinical impression that histrionic behavior often accompanies the disorder. Further research with SD patients is needed to examine the relationship of co-occurring personality disorders to symytom recurrence, health care utilization, and readiness for psychiatric referral.
Introduction The diagnostic complexity and lenge of treating patients with order (SD) extends much further multiple, unexplained somatic
therapeutic chalsomatization disthan their chronic, complaints. Pre-
From the Departments of Psychiatry (KMR, RNA, GRS) and Medicine (GRS), University of Arkansas for Medical Sciences, and the VA HSR&D Field Program for Mental Health (GRS), Little Rock, Arkansas; and the Department of Psychiatry, Emory University, Atlanta, Georgia (FWB). Address reprint requests to: Kathryn Rost, Ph.D., University of Arkansas for Medical Sciences, Department of PsychiatrySlot 554, 4301 W. Markham Street, Little Rock, AR 72205.
322 ISSN 0163-8343/92/$5.00
vious work has demonstrated that SD patients have substantial comorbid Axis I diagnoses. Depressive disorders have been diagnosed in 55%-94% of SD patients, panic disorder in 26%-45% of SD patients, and alcohol abuse or dependence in 17%-31% of SD patients [l-4]. However, what many clinicians find most striking about SD patients is their Axis II psychopathology. Experienced clinicians often find themselves managing the characterological problems of SD patients as often as managing the somatization itself. This task is complicated by the fact that physicians’ impressions about common personality disorders in SD patients are different than those described in the literature. This study reports the distribution of DSM-III-R personality disorders in a large cohort of SD patients from a primary care setting. Given its clinical importance, relatively little is known about the prevalence of Axis II disorders in these difficult-to-manage patients. Only histrionic and antisocial personality disorder have been extensively investigated in SD patients. Histrionic personality disorder has been frequently studied because hysteria is noted to be the forerunner of modern-day SD. In three studies of SD patients in psychiatric settings, estimates of co-occurring histrionic personality disorder range from 54.1% to 81.8% [5-71. A fourth investigation estimated the co-occurrence of histrionic personality disorder in psychiatric patients with somatoform disorders to be only 7.4% [a]. Antisocial personality disorder (ASP) has been studied because its co-occurrence with SD has important implications for psychiatric nosology. Cloninger et al. [9] have proposed comGo~rnlHuspir~IPsycl~intry14, 322-326, 1992 0 1992 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Personality
mon etiologic and pathogenic factors for ASP in men and SD in women. When psychiatric outpatients with SD are considered, rates of co-occurring ASP range from 3.6% to 16.770, with higher rates among psychiatric patients described as refractory (53.1%)) [6], inpatients (25.0%) [3], and felons studies demonstrate (63.0%) [lo]. C om p arative that the prevalence of ASP in men with SD was 3.5 times greater than in women with SD [ll]. Studies of personality disorders in patients with multiple unexplained physical complaints, presumably including some patients with SD, have been reported for only three cohorts. Among 14 psychiatric patients diagnosed with a somatoform disorder, structured interviews indicated that 64% had at least one personality disorder. The most frequently identified personality disorders were avoidant, dependent, borderline, and compulsive [12]. In a second study of 27 psychiatric patients with a somatoform disorder, psychiatrists diagnosed only 30% of patients with a personality disorder; dependent and mixed disorders were the most common IS]. In a third study of 100 patients referred to a consultation-liaison service for evaluation of medically unexplained symptoms, only 4% were diagnosed with a personality disorder. Though this is considerably lower than the other two estimates, only 34% of patients in the cohort received a diagnosis of somatoform disorder [13]. Although they represent the most systematic studies to date of personality disorder in somatoform patients, these studies utilized small sample sizes and produced inconclusive results about the comorbidity of personality disorders and SD. Even if clear trends existed, it is questionable whether the rates of personality disorders in psychiatric patients with somatoform disorders are generalizable to most SD patients who seek treatment primarily in medical settings [4,14]. To address these limitations in the research to date, we designed a study to identify the distribution of all DSM-III-R personality disorders in a large cohort of patients with SD currently in treatment in primary care settings.
Methods This study was conducted in conjunction with a pilot study and a subsequent full-scale investigation of a consultation-liaison intervention to promote cost-effective care for SD patients described at length elsewhere [15]. Patients were recruited from practicing primary care physicians within
Disorder
in Somitization
Disorder
a 30-mile radius of Little Rock, Arkansas and provided informed consent to the investigators. Somatization disorder was diagnosed by semistructured interviews conducted by a research psychiatrist who determined whether patients had a lifetime history of 44 physical symptoms, including the 37 symptoms used to make the diagnosis of somatization disorder. A thorough medical record review was used to identify reported symptoms that were not medically explainable. The research team also administered the Diagnostic Interview Schedule (DIS) [16] and collected information on each subject’s social and surgical history. All subjects were then given the Structured Clinical Interview for Diagnosis of DSM-III-R Personality Disorders (SCID-I’D) [17] by one of three clinicians after the clinician reviewed DIS diagnoses to evaluate whether Axis I psychiatric disorders were influencing responses during the personality disorder interview. With the SCID-I’D, each criterion for 13 DSM-III-R personality disorders was scored for severity to determine whether each disorder was present, subthreshold, or absent. Though we did not have the opportunity to characterize interrater reliability among the three clinicians, the test-retest reliability of the SCID-I’D has proved adequate for the diagnosis of personwith kappas averaging 0.50 at 2ality disorders, week retest.
Results Subjects recruited to the study were 85.1%’ female, 76.8% white, and 67.0% married. In terms of education, 63.8% of the sample were high school graduates or above. Mean age was 43.2 (SD = 10.0). Though 39.4% of the sample had no identifiable personality disorder, 23.4% had one diagnosed personality disorder. Two personality disorders were identified in 13.8% of the sample; three or more disorders were identified in 23.4% of the sample. The prevalence of any personality disorder did not vary for subjects who completed the SCID-I’D before, during, or after the original study’s intervention (x” = 1.42, two tailed p = 0.49). Table 1 illustrates the prevalence of each personality disorder in the sample. The most frequently identified disorders were avoidant 26.7%, paranoid 21.3%, self-defeating 19.170, and obsessive-compulsive 17.0%. Histrionic personality disorder was identified in 12.8% of the sample and antisocial personality disorder represented only 7.4% of the sample. 323
K. M. Rost et al.
Table
1. Frequencies of DSM-III-R personality disorders diagnosed in a sample of somatization disorder patients referred from primary care settings (N = 94) and a sample of general medical patients (N = 87) Frequency of
DSM-III-R personality
disorder (%)
disorder
Avoidant Paranoid Self-defeating Obsessive-compulsive Schizotypal Histrionic Borderline Dependent Passive-aggressive Antisocial Schizoid Narcissistic Not otherwise specified Data describing
general
medical
Frequency of subthreshold
26.7 21.3 19.1 17.0 14.9 12.8 10.6 8.5 8.5 7.4 3.2 3.2 2.2 patients
8.5 17.0 14.9 12.8 11.7 10.6 14.9 12.8 9.6 3.2 5.3 6.4 0.0
Frequency of disorder in general medical patients (%) 2.3 2.3 2.9 6.3 0.6 4.6 3.4 1.7 3.4 1.7 1.1 1.1 -
in this table are from First et al., unpublished.
We were not able to conduct SCID-PD interviews with a comparison sample of non-SD patients, but we can compare the prevalence of personality disorders in our population to the prevalence of personality disorders as determined by the SCID-I’D reported in a general medical population (M. First et al., unpublished data). Personality disorders are 2.5-11.6 times more common in SD patients in our sample than they are in general medical patients, a group that presumably includes some patients with nondiagnosed SD.
Discussion The 61% co-occurrence of personality disorders in 94 primary care SD patients is surprisingly comparable to the findings of the previous study of psychiatric patients with somatoform disorder where structured interviews demonstrated that 64% had at least one personality disorder [12]. These studies suggest that personality disorders deserve considerable clinical attention because they are widespread in SD patients, and represent a notably different spectrum of disorders than the previous literature would suggest. Somatization disorder does not appear to be associated with any one or combination of currently defined personality disorders. Though most studies of psychiatric patients report that over half of all SD patients have histrionic personality disorder, the disorder could be diagnosed in only 12.8% of SD subjects recruited in this study of primary care
324
disorder (%)
patients. Similarly, the 7.4% prevalence of ASP in primary care SD patients is much less than the cooccurrence of ASP in most studies of psychiatric patients with SD. One explanation for this difference is that the acting out associated with antisocial personality and histrionic disorders results in earlier identification of the patient’s psychiatric problems and treatment in the mental health care setting. Instead of dramatic personality disorders (histrionic and ASP), the most common Axis II disorders in this primary care sample were from the anxious or odd cluster. The high prevalence of avoidant personality disorder we found in SD patients is not surprising. The development of symptoms may allow SD patients a ‘legitimate’ reason to avoid a decision or the opportunity to see the physician who may then be manipulated into making a decision that the patient desires to avoid. The high prevalence of paranoid personality disorders in this group reflects the discomfort that many SD patients have with their own feelings. Though paranoid personalities classically deal with this discomfort by attributing their fears to external causes, they may also see their own body as ‘against’ them. It is somewhat of a paradox, however, why SD patients with paranoid personality disorder pursue physicians so adamantly after repeated failure to obtain help from them. It is plausible that this subgroup of patients has a greater frequency of doctor shopping, as they are more likely to see the doctor as an enemy instead of an ally.
Personality
The high prevalence of self-defeating personality disorder in SD patients reflects a deranged selfimage which prevents them from believing that they deserve anything good, including the possibility that they may be healthy rather than defective. The high prevalence of obsessive-compulsive disorder also sheds light on SD patients’ excessive symptoms in the absence of signs of disease. These patients may believe that it is only their hypervigilance that prevents them from becoming sick; thus, they amplify normal physiological variation into discomfort or illness. It appears likely that all these personality disorders contribute to SD patients’ notorious reluctance to discuss psychological issues in their treatment [lS], as clinicians have noted that many of these disorders are often associated with a lack of psychological mindedness. Patients who somatize preferentially seek care in the medical sector [4,14] where primary care physicians and specialists often fail to consider any psychiatric diagnosis in their elusive and expensive search for an organic cause [19]. SD is a relatively infrequent problem in the general population [4], but SD patients represent as many as 5% of patients seen in outpatient medical clinics [20] and 9% of admissions to general medical and surgical services [21]. These findings can help primary care physicians recognize SD patients and anticipate management issues that may emerge in the doctorpatient relationship. As to recognition, SD patients generally will not present in the exaggerated manner characteristic of patients with dramatic personality disorders. Rather, SD patients will present with anxious or odd characteristics. In the doctorpatient interaction, they are less likely to be demanding and more likely to be needy (anxious) or unusual (odd). Management approaches that physicians usually use with patients with dramatic personality disorders will be less effective. Instead, physicians will need to be more supportive and flexible in order to deal effectively with many SD patients. Our characterization of the prevalence of various personality disorders among SD patients is limited by current methodology to diagnose Axis II disorders. We were especially concerned that the presence of an Axis I diagnosis other than SD would confound our measurement of personality disorders, so we systematically informed clinicians of subjects’ Axis I diagnoses before they assessed personality disorders. Analyses in addition to the ones we present in this paper indicate that this methodology resulted in comparable likelihood of per-
Disorder in Somitization
Disorder
sonality disorders in patients with and without an Axis I diagnosis other than SD. Though not conclusive, these results are consistent with the hypothesis that Axis I psychopathology did not substantially confound our measurement of personality disorders. Future research is needed to investigate how personality disorders affect the course and outcome of treatment provided patients with SD in medical settings. Other investigators have found that personality disorders alter patient response to treatment for major depression [22] and panic disorder [23]. Further research is needed to understand the relationship of personality disorders in SD patients to clinically important variables such as frequency of help seeking, functional impairment, health care expenditures, and readiness for psychiatric referral. If particular personality disorders can be linked to poorer outcomes and excessive utilization, clinical interventions targeted to this special group of SD patients can be designed and tested for their cost effectiveness in primary care settings.
References 1. Brown FW, Golding JM, Smith GR: Psychiatric comorbidity in primary care somatization disorder. Psychosom Med 52445-451, 1990 2. Liskow B, Othmer E, Penick EC, DeSouza C, Gabrielli W: Is Briquet’s syndrome a heterogeneous disorder? Am J Psychiatry 143:626-629, 1986 3. Liskow B, Penick EC, Powell BJ, Haefele WF, Campbell JL: Inpatients with Briquet’s syndrome: presence of additional psychiatric syndromes and MMPI results. Compr Psychiatry 27:461-470, 1986 4. Swartz M, Landerman R, George L, Blazer D, Escobar J: Somatization disorder. In Robins LN, Regier D (eds), Psychiatric Disorders In America. New York, Free Press, 1990 5. Kimble R, Williams JG, Agras S: A comparison of two methods of diagnosing hysteria. Am J Psychiatry 132:1197-1199, 1975 6. Lilienfeld SO, VanValkenburg C, Larntz K, Akiskal HS: The relationship of histrionic personality disorder to antisocial personality and somatization disorders. Am J Psychiatry 143:718-722, 1986 7. Morrison J: Histrionic personality disorder in women
325
K. M. Rost et al.
8.
9.
10.
11.
12.
13.
14.
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