Psychosomatics 47:163-166, April 2006
doi: 10.1176/appi.psy.47.2.163
© 2006 Academy of Psychosomatic Medicine
Somatization or Psychosomatic Symptoms?
Lazslo Antonio Ávila, Ph.D.
Received February 9, 2005; revised March 10, April 6, 2005; accepted May 13, 2005. From the Medical College of São José do Rio Preto, São Paulo, Brazil. Address correspondence and reprint requests to Dr. Ávila, Rua Saldanha Marinho–3564, São José do Rio Preto, São Paulo, Brazil CEP 15014-300. e-mail: lazslo{at}terra.com.br
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ABSTRACT
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The author describes some problems emerging from the approach to and comprehension of somatization symptoms, discussing ambiguities regarding somatization seen in the current classification manuals (ICD-10 and DSM-IV). Then the author presents a case report of a man who presented with a bizarre symptom of feminization that was successfully treated with psychotherapy. The author ends with a discussion of the relationship between meaning and symptom.
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INTRODUCTION
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Somatization poses a major problem in general health, as well as in the classification of diseases. If taken in the broad sense, where no detectable organic pathology is evident, somatization is very prevalent in the general population, representing around 50% of all medical consultations at the primary-care level.1–4 Nevertheless, in the strict sense of "Somatization Disorders" (International Code of Diseases, 10th Edition [ICD-10] F 45; Diagnostic and Statistic Manual of Mental Disorders, 4th Edition [DSM-IV] 300.8), epidemiological studies have found only about 0.3% of the general population to be affected.5,6 Within the range of from less than 1% to almost half of the patients consulting doctors, a large number of people suffer from nonorganic, or "functional," illnesses. These patients receive diagnoses covered by several labels, from the most precise to the less-defined "neurovegetative disorders," "petit hysterie," "hypochondria," "neurasthenia," "multiple chemical sensitivities," "stress," "burnout syndrome," "chronic fatigue syndrome," "psychosomatic illness," etc. All of these terms may be (and constitute) very different medical conditions, but they express a deeper "indeterminateness," not only in terminology, but also in conception.
Some authors, such as Trillat,7 proposed that all of this confused terminology is derived from the exclusion of the broad category of "hysteria" from the large medical classifications. The ICD-10 decided to exclude this term because of the variations in meanings in different countries and psychiatric traditions. The authors brought together by the World Health Association decided to create two different classifications: one for dissociative and conversive symptoms (F 44), and the other for somatoform disorders, including hypochondria (F 45). Alternatively, the American Psychiatric Association's DSM decided to create a broad group, including dissociative (300.12), conversion (300.11), somatoform (300.81), and undifferentiated somatoform (300.82) symptoms, hypochondria (300.7), and pain disorders (300.7). These classifications have been under scrutiny in recent years and have been criticized, particularly in relation to the "somatoform disorder" classification. Wise and Birket-Smith, in an editorial, declared: "Unfortunately, the somatoform disorders continue to be problematic and need significant revision. ... Both the process of the DSM work group and the content of the somatoform section demand rethinking."8
To further confuse this already-complex situation, there exists a large group of "medically unexplained" symptoms. This group of symptoms has received a lot of attention in recent years.9–11 One of its "last-but-not-least" problems is to differentiate what is really unexplained because of still-unknown pathologies and what reflects the influence on the organic of extraorganic factors, which include the psychological (both conscious and unconscious), the familial, social, geographical, historical, cultural, and ecological.
Health is a matter of multiple domains, and a myriad of perspectives is coherent with its complexity. Many different viewpoints are necessary in order to reconstruct the totality that the analytical tradition in science has fragmented in so many specialties. Medicine, with all its subdivisions; psychology, sociology, anthropology, history, and economics are all valid approaches, in addition to biology, physics, and chemistry, in the comprehension of what happens in both the sick and the healthy human being. Pathology, although a solidly-defined field with epistemological legitimacy, is a place where the boundaries are in constant movement, and biology alone cannot provide the totality of answers required.12
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Case Report
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The patient, a 38-year-old truck driver, was in the process of securing early retirement. In fact, his "disease" consists of a single bizarre symptom: although he is a big and tough man, his voice has a very feminine tone, similar in timbre to a woman's—high-pitched and smooth. He came for a psychosomatic consultation in the outpatient clinic of the University Hospital (Medical College of São José do Rio Preto, Brazil), after 3 years of follow-up in the Ear, Nose, and Throat Department.
When I started to treat him, he had recently investigated having surgery, but the throat surgeon considered that there was no problem in his vocal chords or his larynx. He had a long medical history, having made many consultations in several different specialties, with no results. There was no medical explanation for his symptom—no obvious organic causality.
This man, working in an environment where the values and the ideology are strongly marked by presuppositions of male superiority and where homosexuality is mostly viewed with animosity, resulting in great prejudice, was suffering a very difficult conflict. He, in his inner self, knew that he was not a homosexual, but could not, by himself, be freed of this external sign of femininity. Thus, since his symptoms had worsened, he received permission to be absent from his job, but after several "sick notes," he now had to either face retirement or return to his job. This situation increased his anxiety, and, although he remained convinced that his condition was physical and in no way psychological, he finally accepted a psychological evaluation.
In his first consultation, he told me that his only problem was his voice. He was very happy with his family life, was emotional and sexually satisfied with his wife, had great tenderness with his two daughters, and evaluated his personal life as well-adapted. He had friends, a good relationship with his mother and brothers, and a relatively good standard of living, belonging to the lower-middle class, without any real economic problems.
Apparently, he could not recognize any psychological origin to his affliction and, in fact, showed a clear tendency to identify all his problems as a somatic illness of unknown cause. Very reluctantly, he agreed with my proposal to review some aspects of his personal life. I focused on the very beginning of his symptomatology, asking him to reconstruct all relevant facts pre-dating the onset of his symptoms.
During this analysis, the following stressful situation was brought to light: 3 years earlier, he had involuntarily caused a serious traffic accident. Although nobody died, his firm suffered serious financial harm, which cut into company profits, and his boss harshly admonished him. This man, his superior, was a brutal man, who told him that he was incompetent and irresponsible (along with some other, unrepeatable expressions), indicating that he was not a complete man. The patient felt as if he was a child being beaten. The whole situation seemed to him as if he was suffering sodomy by his boss. He became very nervous and felt deep anger, but showed no reaction. As he described it, he felt a desire to kill the man, but, of course, as a moral being, he restrained himself.
A few months later, the boss severely reprimanded another worker, humiliating him in public. But this man reacted violently, and, in the fight that followed, he stabbed the boss. After the death of this man, the patient felt sick. Starting with flu, he had a fever and cough, and he suddenly lost his voice. He was aphonic for 2 weeks, and, when he recovered, he could not maintain his previous pitch, and his voice became feminine. Then, he started his long journey of examinations, diagnoses, and "doctor's excuses." There were some fluctuations, and sometimes, with no reason, his voice improved, returning to its previous modulation. But he could not identify the reasons for exacerbation or remission.
The mere fact of reconstructing the origin of his symptoms gave him hope, and his voice became better, taking on a deeper tone. But the analytical work had to penetrate more profound layers, and, at a frequency of two sessions per week, we worked on investigating other links.
The success of recovering his voice and our good relationship favored his desire to submit himself to the analytical process, and we established a good therapeutic setting. Inside the transference, his emotional life could be explored. First, the focal point was the figure of his boss, and, slowly, through painful investigation, came the memories of his relationship with his deceased father.
The patient had a very domineering father, an illiterate man, harsh and insensitive, who frightened the patient and was simultaneously loved and hated. A very difficult father–son interaction developed until the patient entered his early teens. Then, suddenly, his father died. The family lived through tough times, almost subsisting on charity. At this point, the patient started working and helped his family to survive. After this, he married, and his life moved on. All the facts concerning his childhood were buried, and he could barely remember some feelings. When the analytical work reached these memories, many repressed feelings arose, and the sessions had a "cathartic" aspect. Curiously, his voice followed the pattern of the analysis, and, after each discovery, his voice was strengthened. The fluctuations became rare, and finally he felt confident enough to return to his job.
The total treatment lasted 1 year, with another year of follow-up. At the end of the process, there were no signs of feminization in his voice. This process helped him to become a man who was much more conscious of his emotional reactions and, hence, of others' emotions, too. No other physical problems emerged.
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Discussion
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What did this patient suffer from? The diagnosis was "Somatoform Disorder" (ICD-10, F 45; DSM-IV, 300.8), but he could also be considered a "psychosomatic" patient. The label here means less than the processes that caused his somatization. Our work was centered in the search for the meanings that were both expressed and simultaneously disguised by his physical symptom.
The patient's suffering seems like a hysterical condition, a conversion symptom. Our psychotherapeutic approach was based on a psychoanalytical perspective. We looked for the unconscious structure that could be responsible for such a manifestation. Why would a man adopt a trait so typical of a woman, and thereby endure a storm of consequences so negative that he would have avoided them at any cost? It is possible that all this patient's agonizing started with a bad conjuncture: a re-emergence of his oedipal conflicts brought to light in an existing context.
We understand that, in his adulthood, this man suddenly was confronted with the unconscious structure of his Oedipus complex, as the matrix of his relationships with authorities. This matrix acted as the departure point and the model for the constitution of his symptom. Before his powerful father, this subject felt an ambiguous mixture of love, hate, and fear; before his boss, these feelings re-emerged, as the drama became explosive, and formed a fantasy of murder. When reality, in a combination of bad luck and disgrace, concretized this unconscious desire, a deep sense of culpability emerged. To deal with this, and to prove that he would never be capable of such an act, he took on a female role. As a "woman," he could not be responsible for this death. His psychosomatic symptom was a complex formation made up of the proof of innocence and, contradictorily, as a punishment for the forbidden act.
The psychotherapy cured the symptom when its "cause," or, better, its meaning, was identified. Further studies should provide a means to better understand the mechanisms of the origin of such somatization of feelings.
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REFERENCES
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- Allen LA, Gara MA, Escobar JI, et al: Somatization: a debilitating syndrome in primary care. Psychosomatics 2001; 42:63–67[Abstract/Free Full Text]
- Servan-Schreiber D, Kolb NR, Tabas G: Somatizing patients, part I. Am Fam Physician 2000; 61:1073–1078[Medline]
- Garcia-Campayo J, Claraco LM, Sanz-Carrillo C, et al: Assessment of a pilot course on the management of somatization disorder for family doctors. Gen Hosp Psych 2002; 24:101–105
- Kronke K, Arrington ME, Mangelsdorff AD: The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990; 150:1685–1690[Abstract]
- Ladwig KH, Marten-Mittag B, Erazo N, et al: Identifying somatization disorder in a population-based health examination survey: psychosocial burden and gender differences. Psychosomatics 2001; 42:511–518[Abstract/Free Full Text]
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- Trillat E: Historie de la Hysterie. Paris, Seghers, 1986
- Wise T, Birket-Smith M: The somatoform disorders for DSM-V: the need for changes in process and content. Psychosomatics 2002; 43:437–440, editorial, p 437[Free Full Text]
- Ávila LA, Wessely S: Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J R Soc Med 2003; 96:223–227[Free Full Text]
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- Ávila LA: Doenças do Corpo e Doenças da Alma: Investigação Psicossomática Psicanalítica. São Paulo, Escuta, 1996
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ABSTRACT
INTRODUCTION
