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Neurosurgery & Psychiatry Journal ofNeurology, Neurosurgery, and Psychiatry 1994;57:1161-1164 1 161 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.10.1161 on 1 October 1994. Downloaded from Journa of NEUROLOGY NEUROSURGERY & PSYCHIATRY Editorial Somatisation in neurological practice The diagnosis chronic disorder with onset before the age of 30 and The average British neurologist, according to a recent multiple symptoms pertaining to various systems-is also survey,' will fail to find an adequate physiological expla- included here. nation for the symptoms of one in every five of his or her Within the wider concept of somatisation, hysteria, or patients despite appropriate, often exhaustive, investiga- conversion disorder, if narrowly defined, refers to those tions. In some patients organic pathology may be pre- unexplained symptoms suggestive of neurological disease sent, but the symptoms and the ensuing disability cannot (loss of function or sensation) and has the doubtful dis- be satisfactorily explained as a result. According to Mace tinction among psychiatric diagnoses of still invoking and Trimble,' the authors of the survey, as many as "Freudian" mechanisms as an explanation. The idea that 36 000 such patients may be seen by British neurologists a traumatic experience, usually of a sexual nature, could every year. Surveys of neurological inpatients have be rendered innocuous by being transformed into a produced equally striking results. In a recent study of 100 somatic symptom5 is central to the diagnosis. The resolu- consecutive new admissions to a neurological ward an tion of this unconscious conflict is the primary gain and adequate organic explanation for the symptoms was only the advantages resulting from the assumption of the sick forthcoming in 40 of them, whereas in the rest organic role are known as the secondary gain. This legacy of the pathology was absent or provided only a partial explana- psychoanalytical era is still embodied in the current tion.2 Reports from general medical settings echo these DSM-III-R criteria, which include a temporal relation findings3 and it is generally assumed that psychological with relevant psychological stressors and an "uncon- and social factors are important in determining these scious" motivation for the symptoms. In practice, how- unexplained symptoms. The search for a psychiatric ever, these criteria are vague and difficult to establish. In diagnosis wide enough to fit patients whose symptoms the previously quoted survey of British neurologists' rele- http://jnnp.bmj.com/ are partly explained by organic pathology as well as those vant psychological factors were only evident in a third of in whom such explanation is not forthcoming, and the cases, suggesting that they may be difficult to elicit or precise enough to provide a pathophysiological explana- have limited clinical relevance. Similarly, the degree of tion for such diverse symptoms continues to exercise insight may vary depending on the duration of symptoms psychiatrists and neurologists alike. and contact with the medical profession. A brief definition of "somatisation", a concept well Unexplained neurological symptoms are often part of a discussed by Lipowsky,4 is appropriate here, as it pro- more widespread picture of somatisation and strict diag- vides a useful way to categorise these symptoms and to nostic boundaries are of little clinical relevance and diffi- on September 28, 2021 by guest. Protected copyright. bypass fruitless diagnostic controversy. Somatisation can cult to delineate. Here the broad definition of be defined as a tendency to experience and communicate somatisation is used to encompass neurological and other somatic distress and symptoms unaccounted for by symptoms for which no obvious organic explanation is pathological findings, to attribute them to physical ill- forthcoming. This is, in my view, and hopefully in that of ness, and to seek medical help. It is usually assumed that the readers, more clinically sound than the artificial com- somatisation occurs in response to psychosocial stresses, partmentalisation proposed by diagnostic classifications. although this may not be recognised by the patient, or In doing so, however, caution has to be exercised in may be actively denied. Thus defined, somatisation interpreting the results of studies with different defini- encompasses a wide spectrum of symptoms referred to tions of what constitutes somatisation or conversion dis- various organs or systems, appearing acutely or over order. Pain will not be dealt with here for reasons of many years and mimicking a variety of diseases. In many space, but much of what is contained in this editorial also patients the unexplained somatic symptoms may be an applies to the symptom of pain when it appears as part of integral part of depression or anxiety, whereas in others the clinical syndrome of somatisation. "classic" psychiatric symptoms are absent and the mental Given the difficulties in establishing the diagnosis, it is state may seem to be entirely normal. The categories of not surprising that the reported prevalence of somatisation conversion disorder or hysterical neurosis, conversion varies depending on the setting. Thus in the previously type (DSM-III-R), or dissociative/conversion disorder quoted survey of British neurologists' 20% of patients (ICD-10), are included within the wider concept of had non-organic symptoms, a similar rate to that quoted somatisation. Briquet's syndrome-a narrowly defined, by United States neurologists.6 In a United Kingdom 1162 Editonial J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.10.1161 on 1 October 1994. Downloaded from survey of patients admitted to a neurological ward7 an logical diseases has not been systematically studied. adequate organic explanation for the symptoms was Claims made that this association was common in multi- forthcoming in only a third of the patients, whereas in a ple sclerosis22 have not been substantiated23 and it quarter, a purely psychological explanation was more remains to be explored whether damage to specific brain appropriate. For the remainder, a mixture of organic and structures (for example, the frontal lobes with the attend- psychological factors seemed relevant and clinicians were ing impairment in executive and attentional functions) often at a loss in trying to find appropriate diagnostic results in an increased vulnerability to develop conver- labels. A more recent study of consecutive acute neuro- sion symptoms. logical admissions in Denmark2 reported an adequate Association with other psychiatric diagnoses, especially organic explanation for only 40 out of 100 patients. As depression, is common. A 50% lifetime prevalence for can be expected the prevalence of Briquet's syndrome, depression9 and 20% for panic disorder have been the most severe and chronic form of somatisation, is reported in patients with multiple somatic symptoms much lower (2 per 1000 in a United Kingdom general without organic pathology.24 In cross sectional studies practice survey).8 major depression has been detected in over 50% of these In children, unexplained physical symptoms are com- patients. In those with narrowly defined conversion dis- mon and minor abdominal or limb pains and headaches order, affective symptoms seem to be less common with a without organic cause have been reported in up to 20% frequency of under 30% in cross sectional studies,24 of school children,9 but account for less than 1% of chil- although few reports separate these patients from those dren admitted to hospital. Unexplained neurological with multiple somatic symptoms. The frequent associa- symptoms make up about 2% of the referrals to paedi- tion of somatisation and affective disorder raises the pos- atric neurologists'O11 and this presentation is rare before sibility that affective disorder may be a predisposing the age of six.'2 The symptoms children exhibit are not factor and not simply a reaction to disability. Psychiatric substantially different from those seen in adults and mul- symptoms are often overlooked in these patients, who tiple symptoms are also common. In young children tend to minimise or explain away psychological distress. unexplained somatic symptoms are equally frequent in This inability to acknowledge and express emotional boys and girls, but in adolescence, females predominate nuances has been called "alexithymia" and it is probably (3:1). an important determinant in the somatic presentation of Somatisation, including conversion disorder seems to psychiatric symptoms. be commoner in those of low socioeconomic status,'3 and Psychiatric comorbidity seems to be less severe in chil- dramatic changes in prevalence have been associated with dren and adolescents with unexplained somatic and neu- improving education and greater prosperity in communi- rological disorders.25 Good premorbid adjustment is ties studied prospectively.3 "4 In these communities the common and when present emotional disturbances are overall psychiatric morbidity remained unchanged, with only mild.26 Sexual abuse and bereavement are only rele- depression becoming commoner as somatisation waned, vant in a minority of children and overt family pathology an indication of the complex link between these condi- has been found in less than a quarter of cases.27 On the tions. other hand, sociocultural factors and physical or psychi- atric illness in other family members are particularly rele- vant in these children.28 Comorbidity The association of brain disease and narrowly
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