Psychosomatics 42:511-518, December 2001
© 2001 The Academy of Psychosomatic Medicine
Identifying Somatization Disorder in a Population-Based Health Examination Survey
Psychosocial Burden and Gender Differences
Karl-Heinz Ladwig,
Birgitt Marten-Mittag,
Natalia Erazo, and
Harald Gündel
Received April 2, 2001; revised July 31, 2001; accepted August 20, 2001. From the Institut und Poliklinik für Psychosomatische Medizin, Med. Psychologie und Psychotherapie des Klinikums Rechts der Isar der Technischen Universität München; and the GSF—Research Center for Environment and Health, Institute of Epidemiology, München-Neuherberg, Munich, Germany. Address reprint requests to Dr. Ladwig, Institut u. Poliklinik für Psychosomatische, Medizin, Psychotherapie u. Med. Psychologie, Klinikum rechts der Isar der TUM, Langerstrasse 3, 81675 München, Germany. E-mail: ladwig{at}gsf.de
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ABSTRACT
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Despite its enormous medical burden, little is known about the epidemiology of somatization in the community. The present study screened a representative population-based survey of 7,466 subjects in the age range of 25 to 69 years for the occurrence of somatization. A total of 137 (1.84%) individuals experienced six or more symptoms from at least two different body sites without an identifiable organic cause. These patients exhibited a lower quality of life (P 0.0001) and suffered from higher levels of emotional stress (P0.0001) than their counterparts in the healthy subsample (n=906). Somatization was not associated with a medical diagnosis, but disability days, the use of medical services, and the level of medication was higher in the somatization disorder group (P0.004). The somatization risk was only 1.6-fold higher for women in comparison to men but escalated for women rapidly to an approximately 4-fold risk when being female was combined with low social class and high emotional distress. Against expectation, the somatization risk for men also mounted 3-fold under the identical risk constellation.
Key Words: Somatization Disorder • Gender Differences • Quality of Life
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INTRODUCTION
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Somatization disorder refers to the preoccupation with multiple physical complaints suggestive of a somatic disease for which a clear physical etiology and an adequate medical explanation cannot be found.1 Studies in medical and psychiatric populations suggest that somatization disorder entails high personal, social, and even corporate costs because of high indexes of disability and frequent sick leaves.2,3
Despite its enormous medical burden, little is known about the epidemiology of somatization in the medical community.4 Most of the data have been derived from clinical contexts. In primary care, somatoform disorders account for approximately 20%—25% of consultations.5 A Dutch study showed a prevalence of 25% of somatoform disorders among new referrals to a general medical outpatient clinic.6 Even among medical inpatients, 18% met criteria for somatization disorder.7
Faravelli et al.8 were among the first to undertake a community based survey of somatoform disorders conducted in Florence, Italy. In their inquiry, the most frequently encountered somatoform disorder was the undifferentiated somatoform disorder, with a 1-year prevalence of 13,8%. The prevalence of somatization disorder was 0.7%.8 Lieb et al.9 recently screened for somatization in a representative population sample of 3,021 adolescents and young adults age 14–24 years in Germany and assessed a lifetime rate of 2.7%.
In clinical practice, somatization disorder is predominantly seen in women.10–13 It is unclear whether higher prevalence rates in women account for a true excess in prevalence or whether the rates are biased by a female-specific pattern of a higher frequency in health care service utilization.14,15 Screening for gender differences in population-based surveys that are not biased by utilization preferences of medical services16,17 may therefore be more appropriate than hospital-based investigations. A general female excess of somatic complaints has been widely confirmed in large community population samples.18–23 Whether those gender differences in symptom reporting meet the criteria of a somatization disorder diagnosis has not been under investigation so far.
The first aim of this study was to examine the prevalence of somatization disorder according to the criteria of the international classification manual of diseases (ICD-10)24 and the amount of personal and social burden associated with the disease condition in a representative health survey of the German adult population. The second aim is to confirm whether subjects labeled as somatizers were more likely to be female.
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METHOD
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The data used in the present analysis have been taken from the National Health examination survey conducted betwee 1990 and 1992 by the Robert Koch Institute in Berlin.25 This cross-sectional survey is a nationwide health examination and interview covering 7,466 subjects whose ages range from 25 to 69 years. It contains a multistage, stratified probability sample for which the subjects were randomly assessed in 150 sample points in all parts of Germany.
The data were gathered through physical examination and interview by medical personnel, and by self-administered standard questionnaires. The physical examination included assessment of height, weight, and systolic and diastolic blood pressure. Blood samples to measure total cholesterol were obtained from subjects lying down in a nonfasting state. A careful medical interview covered data about the participant's medical history.
Participation rate for the survey was 70.2% in the eastern part of Germany and 69.0% in the western part. Participation was not biased by age, sex, or socioeconomic status. The analysis was performed by using a weighting factor provided by the Robert Koch Institute to adjust for deviations in the intended age, sex, community size, and state distribution. More details of sampling, response rates, and methods for the survey are available elsewhere.25
A complete data set of 7,460 subjects was available after excluding 6 cases with missing values. Of these, 906 subjects (15.1%) were not suffering from a physical disease with a confirmed medical diagnosis or a self-reported medical diagnosis. Healthy subjects were significantly younger (P<0.0001), had a higher social status (P<0.0009), and were more likely to be male (P<0.0001) in comparison to subjects with disease.
Efforts were made to capture a group of subjects who approximately meet the criteria of a somatization disorder according to the criteria of ICD-10.24 Somewhat different from DSM-IV,26 ICD-10 prescribes a history of at least 2 years' complaints of multiple and variable physical symptoms that cannot be explained by any detectable physical disorder. The symptom list contains gastrointestinal, cardiovascular, genitourinary, and skin and pain symptoms. The ICD-10 requires at least six symptoms, which should occur in at least two separate domains, and patients presenting symptoms caused by autonomic arousal should be excluded. The ICD-10 does not provide different symptom prevalences for men and women; however, the likelihood of achieving higher counts is higher in women because of the inclusion of female gender-specific symptoms.
The diagnosis of somatization disorder was approached with the Zerssen symptom checklist,27 which is a widely used instrument in German-speaking populations to measure somatic complaints.22,23 The symptom checklist asks for complaints actually perceived. The symptom checklist contains 24 symptoms. It has four options for each item referring to the degree of intensity of experiencing the somatic sensation with a scoring range of 0–3. A high score defines high expressions of somatic preoccupation. To meet the needs of an operational definition of somatization disorder according to symptom counts, the scale was dichotomously categorized. The responses were scored on a Likert scale, giving a potential global scoring range of 0–24.
An inherent weakness of any symptom checklist used to measure somatization disorder in large-scale population studies is to confirm whether the symptoms assessed were explained by true disease conditions or not. To minimize this problem and prevent interfering functional somatic symptoms with medically explained symptoms, subjects were rigorously defined as somatizers only after exclusion of any self-reported disease condition in the health status scale.
These methodological considerations led to the following inclusion criteria for the index study group: a sample person was included if he or she exhibited six or more symptoms from at least two different body sites, which were not somatic equivalents of anxiety or panic attacks. Sample persons were not included if they reported any disease condition with a defined medical diagnosis.
The health status was assessed by asking the subjects whether they were suffering from 31 disease conditions covering an approximately complete range of disease patterns, which are of a measurable prevalence in the population. It was taken in a modified and abridged version from the condition list of the U.S. National Health and Nutrition Examination Survey.28
A medical health care utilization index was composed as a multidimensional index combining additively the following three factors: 1) the frequency of visits to outpatient clinics (0–3 points); 2) the hospital stays during the past 12 months (0–5 points); and 3) the amount and frequency of medical drug use (0–5 points). A total of 21 medical drugs were assessed and then subdivided into three major subgroups: internal medication (10 items), pain-relieving drugs (3 items), and psychotropic drugs (8 items). A sum score was calculated for each subdivision in which the amount and the frequency of utilization were included.
Chronic emotional distress was assessed by a four-item distress scale scoring from 0 to 3 for each item and leading to a Likert global scoring range of 0–12. The scale assesses increased fatigue after mental effort, associated with decrease of coping efficiency in daily tasks and accompanied by feelings of exhaustion and inability to relax.23
A composite social class index (Winkler-Index24) was constructed combining additional levels of education (years of education completed, highest level of schooling achieved), income (total monthly household net income in German marks), and occupational status (seven categories in a modified version of the British Registrar General's Scale), leading to a Likert-like scoring range of 1–21. Low social status was considered when subjects achieved 3–8 points, middle class status was defined as 9–14 points, and upper class status was defined as 15–21 points.
The marital status comprises three categories: 1) single, never married; 2) married/common-law; and 3) divorced/separated/widowed. Social support was measured by responses to the question "On how many persons—including your family—can you rely in case of an emergency?" The one-item scale has a scoring range of 0–4.
The assessment of quality of life was based on eight items with a scoring range of 1–8 covering the domains of occupation, living conditions, income situation, spare time, health, family, friends, and general condition.
Statistical Analysis
The statistical significance of group differences in categorical variables was confirmed with a  2 tests. Mean differences of continuous variables were tested with t-tests and with Mann-Whitney tests if the variables were not normally distributed. All statistical tests were performed two-tailed with  =0.05 as the criterion to indicate statistical significance. To prove the criterion of symptoms from at least two different body sites, a factor analysis was applied to the 24 symptoms of the Zerssen checklist to define different body sites. Principal components analysis with the criteria Eigenvalue over 1 was used for factor determination leading to five factors: F1) dysthymic mood (five items), F2) symptoms involving chest and abdomen (seven items), F3) pain (four items), F4) vagotonic dysregulation (six items), and F5) hypertensive regulation (two items).
To estimate the effects sizes of factors that had an univariate significant association with the disease condition, odds ratios were calculated. A logistic regression model was applied to identify the influence of somatization on the use of medical services after controlling for several confounding variables. To build the model, the use of medical services index was dichotomized. High usage was defined as greater than the median, leading to a sample size of n=671 (75%) in the group with low values of utilization and n=224 (25 %) in the group with high values of utilization (11 cases were excluded because of missing values). Seven variables were included in the logistic regression model: age (continuous), gender, social class status (three degrees), emotional distress (three degrees), social support, general quality of life, and the presence of the somatization disorder. A likelihood ratio statistic was used to select variables for removal from the model by stepwise backward elimination; probability for entry was P<0.05 and for removal was P 0.10. Variable coefficients obtained through logistic regression were interpreted as log odds and converted to odds ratios. Ninety-five percent confidence intervals were computed by exponentiation of coefficient (SE±1.96). The data were analyzed with SPSS for Windows, version 9.30
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RESULTS
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A total of 137 subjects in the healthy subsample of 906 persons met the criteria of a somatization disorder. Thus the prevalence of the disorder was 1.84 % (95% CI 1.54–2.17). The somatization disorder group (Table 1) did not differ from the healthy subsample in age distribution, marital status, or in the level of social support. However, low social status was associated with a high likelihood to exhibit somatization disorder (P0.008).
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TABLE 1. General differences between subjects with somatization (n=137) and without somatization (n=769) from a population sample of 7,460 subjects
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Table 2 indicates that subjects in the somatization disorder group consistently exhibited a highly significant impaired level of various domains of quality of life in comparison to their non–somatization disorder counterparts. Table 3 confirms a significantly higher pattern of disability, medication with drugs from various indications, and use of medical services in the somatization disorder group. Somatization disorder is significantly associated with chronic emotional distress (Figure 1). The prevalence of a high level of distress in the somatization disorder group summed up to more than 50%, whereas a high level of distress in the nonsomatization group was documented in less than 20% of cases (P0.0001).
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TABLE 2. Quality of life in subjects with somatization disorder (n=137) and without somatization (n=769) in the total sample of 7,460 subjects
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TABLE 3. Disability and use of medical services in subjects with and without a somatization disorder in the representative health survey sample
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The somatization disorder risk was 1.63-fold (95% CI 1.13–2.36) higher for women than for men but escalated for women to an 4-fold risk (OR 4.00; 95% CI 1.5—10.6; P=0.002) when female gender was combined with low social class and high chronic emotional distress (Table 4). Accordingly, male gender per se was not a predictor for somatization. However, when low social status was combined with high emotional distress, the risk for men to suffer from somatization disorder rose to a 3-fold risk (OR 3.00; 95% CI 0.9–9.8; P=0.054).
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TABLE 4. Predictors of somatization in the sample of 906 health subjects in comparison to the opposite gender, stratified for gender alone, for gender and social class, and for social class and emotional distress
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We tested the independent influence of age, gender, social class status, emotional distress, social support, quality of life, and presence of somatization disorder on high use of medical services in the logistic regression model. Remaining factors were the presence of somatization disorder with an odds ratio of 1.6 (CI 0.73 - 1.67, P 0.03) against healthy subjects, female gender with an odds ratio of 2.3 (CI 1.67 - 3.13, P 0.0001) against men, and low quality of life with an odds ratio of 2.8 (CI 1.23 - 6.54, P 0.014) against a high quality of life.
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DISCUSSION
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Identifying Somatization
This study identified a subgroup of subjects with a prevalence of 1.84% (95% CI 1.54–2.17) who met the criteria of a somatization disorder according to ICD-10.25 This figure underestimates the true prevalence of somatization disorder because only those subjects who did not have somatic comorbidity were included. Additionally, patients in which hypochondriacal worry has led to the certainty of a medical disorder were not considered in the present analysis either.
Consistent with these restrictions in inclusion criteria, our findings are not generalizable to an entire community population but to those subjects having functional somatic symptoms without an additional definite medical diagnosis or a self-provided doubtful medical diagnosis. The gender ratio and the risks related to gender, social class, and emotional distress might therefore be different had the entire population of somatization disorder in the sample been identified.
The prevalence rates of somatization disorder in the general population vary according to the definition employed.29–31 Prevalence rates in the community are reported to range according to the restricted definition based on DSM-III or ICD-9 rules between 0 and 2.7%3,8,9 and according to the abridged criteria, which are believed to define a "subsyndromal" somatization disorder between 9% and 20%.3,29
The ICD-10 definition provided progress in the clear classification of the disorder. However, when dealing with those patients in a clinical context, doubts remain whether the somatization disorder classification really captures an uniform disorder entity. Kirmayer and Robbins,32 for example, have proposed three definitions of the disorder in distinguishing between patients with 1) functional somatization disorder, defined as high levels of medically unexplained symptomatology; 2) hypochondriacal somatization, which defines patients with somatic preoccupation or hypochondriacal worry; and 3) the somatic clinical presentation of a psychiatric disorder, in which the affective state occurs as a somatized or masked clinical presentation. This study focuses on patients with functional somatization disorder according to this definition, mainly because patients who had a self-reported medical diagnosis were excluded from the analysis.
These restrictions also may explain why the prevalence of somatization disorder diminished with older age groups. In older subjects, the likelihood of a comorbid disease condition rises along with the occurrence of cases in which the symptom picture is not transient or due to a particular psychosocial stressor. Symptoms in these subjects, therefore, may have finally led to a conviction of the presence of a disease process.33–36
Gender Differences
A large empirical body of evidence consistently reveals a female excess in symptom reporting.18–23 Women report more ill health because the sick role may be more socially acceptable to them,37 and in consequence, they may be more ready to define bodily changes in terms of ill health.38 Female patients may also tend to respond affectively when their physical functioning is compromised.39
Significant gender differences in prevalence rates of somatization disorder have been consistently reported.2,8,10–12,34,36,40 Some investigators even have suggested that somatization disorder may not exist in men.12 Cloninger et al.10 also failed to identify male somatizers with clinical characteristics similar to those of female somatizers. They concluded from their data that there is no support for regarding somatization disorder in men as a discrete clinical disorder. Kirmayer and Robbins32 described 81 functional somatizers to be predominantly women, unmarried, and from a lower socioeconomic status. Nevertheless, a proportion of 32% of their study patients were men. Golding et al.11 found that the pattern of multiple unexplained somatic symptoms was more readily detected in women than in men by primary care physicians. Interestingly, Kroenke and Spitzer34 recently found that similar proportions of women and men acknowledged worrying about serious illness, but found increased symptom reporting in women.
Somatization disorder criteria may be biased against diagnosis of men because some of the symptoms are not applicable to them.39 In this study, the symptom checklist contained only somatic complaints eligible for both sexes but clearly proved that gender differences of prevalence rates of somatization disorder exist on a population-based level. The study also confirms that a female excess attenuates significantly when incorporating low social class status and high expressions of emotional distress. These results mirror earlier findings indicating that predisposing factors for somatization disorder include lower social class and less education and culturally acquired attitudes.40 Emotional distress factors may also promote an accelerated interoceptive perception.33,41
Medical Burden
Somatization disorder patients in this study consistently exhibited impaired quality of life and suffered from higher levels of emotional distress. This study also reveals an excess in disability days and in the use of medical services in somatization disorder patients compared to their healthy counterparts and thus confirms that costs for treatment of patients with somatization disorder may extensively exceed the costs of non–somatization disorder subjects in the population.16 Multivariate analysis revealed the influence of somatization disorder for high utilization but also showed that female gender and life stress exhibit even stronger influences on this variable.
Limitations
Limitations of the study should be noted. The classification of a somatization disorder in the present data set did not assess the current ICD-10 onset criterion with a beginning of symptom reporting before age 30. The data of the present investigation are derived from a cross-sectional survey, and therefore no information about the persistence and modification of symptom perception over a time period is available. Recent evidence indicates considerable instability in the recall of lifetime somatization disorder symptoms because of the chronic fluctuating nature of the disorder. Thus, current somatic symptoms may be a more appropriate focus of epidemiological research.42
The list of somatization disorder symptoms did not include female-specific genitourinary symptoms (as in ICD-10). However, the empirical basis for these criteria may also be questioned. The somatic symptoms that are employed in the ICD-10 definition appear to contain a biased selection. The base rate for such complaints in the general population remains unknown and, in addition, has only been seldom investigated in representative surveys.7–9
The strength of this paper is in the use of a larger sample of cases and control subjects than in previous studies and that subjects were selected from the community. As such, the population is more representative of somatization disorder patients than in studies that selected subjects from secondary care. On the other hand, possible organic causes could have remained undiscovered to an unknown degree because of a restricted medical examination. Contrary to the community study of Faravelli et al.,8 in which a psychiatrist and a general practitioner jointly examined the subjects, the health status was evaluated by medical personnel without a particular psychiatric orientation.
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CONCLUSIONS
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This study has demonstrated that a relatively simple algorithm of somatic symptom counting in an apparently healthy subsample of a population-based survey unbiased by utilization preferences15–17 was able to identify a distinct subsample of subjects with medically unexplained symptoms who exhibited impaired quality of life and required extensive medical support. These subjects met the criteria of a somatization disorder according to ICD-10.
One of the most enduring and poorly explained findings about somatization disorder is the preponderance of women with the disorder.10–12 This study confirms this preponderance of female somatization disorder patients. However, the investigation revealed that low social class and high emotional distress impart a significant confounding influence on the gender relationship. According to these data, distressing social and individual conditions may be even more powerful predictors of somatization disorder than female gender per se.
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ACKNOWLEDGMENTS
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The authors are grateful to Sandra Thomas, M.D.. M.S., Chicago Department of Public Health, for her valuable advice in the preparation of this manuscript. This research project was in part supported by a grant of the Bundesministerium für Familie, Senioren, Frauen und Jugend, Bonn-Bad Godesberg.
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ABSTRACT
INTRODUCTION
