Somatization Disorder (Briquet’s Syndrome)
Somatization Disorder is the prototype of all somatizing disorders. Its features can be predicted from the complaints expected to arise from deficits in emotional intelligence in all five of the realms of body awareness described in Table X-1.
|Table X-1. Feature of Alexithymia Grouped According to Planes of Self-Awareness|
|Sexual plane (physical sensations and fantasy)|
|Material plane (motivational drives)|
|Emotional plane (affective attachments)|
|Intellectual plane (emotional communication and symbolization)|
|Spiritual plane (sentiments)|
- The deficits in the sexual plane are frequently associated with distress, multiple bodily pains from a low pain threshold, and sexual or reproductive complaints.
- The deficits in the material plane are frequently associated with low frustration tolerance, poor impulse control leading to substance dependence and violence, and gastrointestinal complaints like irritable bowel syndrome.
- The deficits in the emotional plane are frequently associated with insecure social attachments, little appreciation of beauty, and emotional lability.
- The deficits in the intellectual plane are associated with poor emotional communication, such as being a poor historian with little understanding of emotions of one’s self or others.
- The deficits in the spiritual plane are associated with low quality of life due to a lack of positive sentiments, which leads to a low level of integration of one’s desires, goals, and values. Nevertheless, it is instructive to know how the syndrome came to be recognized and how the current understanding of Somatization Disorder developed historically.
Originally somatization disorder was called chronic hysteria or hysterical neurosis. Patients with hysteria are women in 95% of cases since antiquity so the name was based on the concept from ancient Greece that a wandering uterus caused pains in different parts of the body, which is now largely disproven except in cases of endometriosisOpens in new window.
Eli Robins and Sam Guze developed the modern description of the syndrome and validated it rigorously by follow-up and family studies. According to their descriptions, hysteria was a chronic disorder in which patients had medically unexplained somatic complaints in nearly all organ systems, including multiple bodily pains, gastrointestinal problems, sexual or reproductive symptoms, and pseudoneurological problems (conversion reactions).
The type, number, and distribution of complaints allowed reliable discrimination of patients with a predictable course of illness and characteristic family history, whereas diagnosis and prognosis were unreliable when based on isolated complaints or severity of subjective distress.
Young adult women usually presented with the disorder and their course was chronic, although the specific symptoms varied in location and intensity in response to the viscissitudes of their chaotic lives. The patients had poor affective regulation, were notoriously poor and inconsistent historians, and had little awareness of the relations between the personal and social stresses in their life and their physical complaints.
As a result of the patient’s prominent deficits in emotional intelligence, some people suggested the patients were throw-backs to an earlier point in the evolution of human consciousness. Their way of thinking appears more typical of people who lived about 3000 years ago than it is of the consciousness of contemporary human beings.
Guze carried out blinded follow-up and family studies that showed that patients with this syndrome had a chronic course but were not at increased risk for medical disorders. Studies showed that antisocial personality disorder and hysteria often occurred together in the same individuals as well as in the same families.
Most patients and some psychiatrists disliked the use of the term hysteria because it was rather pejorative and also ambiguous. A French psychiatrist named Briquet had described a similar group of patients with multiple somatic complaints, so Guze suggested the label of Briquet’s syndrome in order to distinguish the syndrome from histrionic personality disorders and acute conversion reactions.
Guze’s criteria were well validated but were cumbersome, requiring endorsement of over 20 out of 59 possible symptoms of Briquet’s syndrome, distributed in at least nine of ten empirically derived groups. As a result, few people used the research criteria in clinical practice.
The widespread nature of the syndrome and its heritability were confirmed in adoption studies conducted in Sweden. Somatizing disorders were also shown to be the major cause of all absenteeism from work, thereby causing great economic loss to society as well as individual suffereing. The adoption studies also confirmed the genetic overlap in the causes of somatizing disorders and personality traits associated with criminality, such as antisocial and borderline personality disorder.
Traditional ways of treating somatization disorder begin with particular attention to the way the diagnosis and a therapeutic alliance are established. Patients with SD are reassured when their physician takes the time to collect a thorough history, obtains past medical records, and obtains collateral information from family members with informed consent. Such careful documentation often corrects inconsistencies and omissions, avoids the need to repeat medical tests, and communicates the respect of the therapist for the dignity and past suffering of the patient.
Comorbid conditions, such as disorders of personality, mood, and substance abuse, are common and may require treatment also. It is useful to assess personality with a questionnaire with internal validity controls, such as the Temperament and Character InventoryOpens in new window, particularly since this is prescriptive of treatment targets. This helps to focus patients on their active role in developing a healthy life by developing greater self-awareness and beginning on the path to their well-being.
No one can be forced to become more self-aware, so there is a wide range of possible goals. The possible goals include at least education to help reduce excessive health care utilization and exposure to unnecessary tests and procedures, as is often done by providing consultation to their primary care physician. It can also include pharmacotherapy for target symptoms of somatic anxiety, depression, impulsivity, emotional detachment, and cognitive distortion. For example, as adjuncts to psychotherapy, antidepressants may be useful for anxiety and mood symptoms, mood stabilizers for impulsivity, and atypical antipsychotics for emotional detachment and/or cognitive distortion.
Cognitive-behavioral therapyOpens in new window has been recommended as a treatment of choice based on a meta-analysis of 29 randomized trials, but the effects were only moderate: symptom severity was reduced in 71% of cases but functional status was only improved in 26%.
A later randomized trial of CBT showed that it can produce moderate but clinically meaningful reductions in health care utilization and subjective complaints for about a year after treatment, even though it does not correct underlying deficits in emotional intelligence. However, relapse and recurrence are major problems for treatments like CBT that do not correct the underlying deficits in emotional intelligence of patients with somatizing disorders. More ambitious work, still unproven by randomized controlled trials, includes efforts focused on the habilitation of emotional intelligence.
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