SOMATISATION

Definitions, symptoms and causes

Somatoform disorder is physical illness without an apparent organic cause,

that is, a functional disorder.

There is a range of somatoform disorders, notably:

 Somatisation disorder: somatoform disorder marked by numerous
recurring physical ailments without an organic basis.
 Conversion disorder (formerly known as hysterical disorder) in which a
need or conflict is expressed in often dramatic physical symptoms.
 Pain disorder associated with psychological factors.
 Preoccupation somatoform disorder in which the person is preoccupied
with the concern that there is something physically wrong with them (but
there is no evidence of any physical disorder).
There is usually no sense in which the sufferer consciously wants or
guides their symptoms, and they usually believe that their problems are genuinely
medical. It is often suggested that causes are psychosocial (Garralda, 1996;
Martin, 1995; Comer, 1999). It is also possible that in some cases there are
undiscovered organic causes.
Here we will focus on the backaches, stomach aches and other somatic
miseries whose primary cause no one seems to know – neither the sufferer, nor
their doctor, family or friends, even though in many cases somatic disorders are
seen to worsen under stress. In spite of reasonable efforts to diagnose and treat
them, they are untreatable using the conventional weapons of orthodox medicine.

Between-group variations in somatic and psychological symptoms

Littlewood & Lipsedge’s (1989) Aliens and Alienists eloquently argues the
idea that there is a derogatory racist stereotype of the formerly subject colonial
peoples – that they are less capable of perceiving feelings within themselves. The
clinical literature sometimes implies that Asians (for instance) are more likely to
express distress somatically than they are to express psychological symptoms,
particularly those of depression. Is this correct? This section gives an overview of
the literature, to see whether this racist stereotype might be confusing
understanding of any between-group differences in the somatic expression of
distress, and also whether somatisation is an alternative to psychological distress.
There are three kinds of study to consider here. First, those studies which
describe forms of somatisation which may be culture specific. Second, studies and
reviews which estimate prevalence in one cultural setting: estimates from different
sources for different cultures may then be compared. Finally, and most usefully
for our present question, studies which compare prevalence of given disorders
between different cultural groups, using the same basis (diagnostic categories and
criteria, and timeframe).

Explanations of these variations

Why might different groups of people experience, describe and express
suffering, or indeed any feelings, differently? The explanations we consider are:
 That there are variations between languages in the way distress is
described.
 That there are culturally carried ‘idioms of distress’ often involving
somatic manifestations, and beliefs in spiritual forces.
 That mental illness and emotional distress are more heavily stigmatised
(especially in tightly-knit/religious groups) than are somatic symptoms.
 That adversity plays a role in causing not only distress but also bodily
dysfunction.

Linguistic.
Hollan (2004), in his account of an Indonesian man suffering from chronic
stomach pains and breathlessness, wondered whether these symptoms were the
result of guilt over youthful misdemeanors, which displeased his parents. This
epitomizes the suggestion that many somatic disorders – and perhaps particularly
somatic disorders – are channeled by linguistic factors.
Bodily metaphor plays an important role in shaping the expression of
distress, as of course does awareness of the autonomic and other physiological
changes that accompany emotion. But the linguistic ‘explanation’ of somatisation
is inadequate in itself. We can see from the examples described that the somatic
expression of distress may be best understood by referring to ethno
methodological understanding of how people in a given culture explain illness.
We have also seen that somatoform disorders consistently ovary with
psychological distress and psychological disorders. We must therefore abandon
any idea that (lack of) language categories may somehow prevent the experience
of psychological distress.

Idioms of distress/culturally shaped beliefs about etiology

Pain and other somatic symptoms are important idioms through which
distress is said to be communicated. Nichter urged an ‘idioms of distress’
approach to psychiatric evaluation. They confirm that somatisation is common in
all ethnic groups and societies studied. There are differences between groups in
prevalence, and this cannot be accounted for in terms of differential access to
health care services.
Analysis of illness narratives suggests that somatic symptoms are located
in systems of meaning that serve many social and psychological functions.
Somatic symptoms may be:
 An index of disease or disorder
 An indication of psychopathology
 A symbolic condensation of intra psychic conflict
 A culturally coded expression of distress
 A medium for expressing social discontent
 A way for people to reposition themselves within their worlds.
Beliefs about spiritual forces can, as the above example suggests, be related to
the somatic expression of distress. Even though causality is difficult to infer, some
clinicians find it helpful to take these beliefs into account. Even though the
‘idioms of distress’ understanding of somatoform disorders has much to
recommend it, other factors may also play important roles.

Stigmatisation – the role of denial

 Bodily symptoms may be more readily displayed, felt or admitted to than are
psychological symptoms for a number of reasons. These include the ‘secondary
gains’ that may be got more readily from somatic than from psychological illness.
Such gains include sympathy and care from the family, sick notes from the doctor,
and sick pay from the employer or the state – all easier to obtain for physical than
for psychological disorders. Then, remedies and ‘fix-it’ solutions – notably
medication – may be easier to think up and offer for somatic symptoms, culturally
approved causal explanations may be more readily available, and physical
symptoms may be less stigmatized. The sufferer may receive less blame, and bear
less responsibility for putting his health in order again.
Fear of stigma could be one of several factors that make it likely that somatic
symptoms will be offered, particularly to the primary medical carrier, rather than
psychological ones.

Psychological factors and stress

Finally, we must consider the relationship of adversity and distress with
somatisation. We can see that several causal pathways are possible. Adversity can
lead to distress, and sometimes to physical damage. There can be a spiralling of
effects, in which distress states may become pathological, and of course distress
states can be caused or exacerbated by physical symptoms.
We can conclude this overview of religion, culture and somatization by noting
that medically unexplained somatic symptoms have been reported in every culture
studied. Symptoms include back pain, digestive and sexual disorders, and
intransigent pain. The lack of ready translations for English words describing
distress (e.g. ‘guilt’, ‘depression’) does not seem to have an influence on the
expression of distress in bodily rather than psychological form. Rather, somatic
disorder is consistently associated with psychological distress and disorder in
every culture studied, and is usually associated with disability.
However, there are variations between groups in forms of somatisation. It does
appear that:
 There are culture-bound idioms of distress, many of them bodily, and often
involving beliefs in spiritual forces.
 Prevalence of specific somatic symptoms varies widely across cultures,
and is not obviously associated with technological advance, prosperity or
access to medical services.
 Although beliefs in spiritual factors can be present in somatoform
disorders, and treatment plans which acknowledge these beliefs may be
recommended by some clinicians, there is negligible material to suggest
that religious factors play a causal role in somatoform disorders.