|Year : 2017 | Volume
| Issue : 3 | Page : 138-142
A study of personality disorders among patients with somatization disorder
Hiam F Elsaied1, Rania A Hamed2, Yared Belay3
1 Department of Psychiatry, Faculty of Medicine, Mansoura University, Mansoura, Egypt; Department of Psychiatry, Madinah Psychiatric Hospital, Madinah, Saudi Arabia
2 Department of Psychiatry, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt
3 Mekelle, Ethiopia
|Date of Submission||19-Jan-2017|
|Date of Acceptance||12-Jun-2017|
|Date of Web Publication||25-Oct-2017|
Candidate of Masters degree, Addis Ababa University, 03, Mekelle, Ethiopia, 03, Mekelle, Ethiopia, Mekelle
Source of Support: None, Conflict of Interest: None
The fact that there is a high association between personality disorders (PDs) and somatization disorder (SD) is widely accepted, to the extent that many expert clinicians find themselves compelled to manage personality traits in patients with SD to obtain good treatment outcomes.
This study was conducted to identify the distribution of all Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR) PDs among patients with SD who were referred from primary care settings.
Patients and methods
This case–control study was conducted from September 2014 to April 2015 and was approved by the Ethics Committee at Al Amal Psychiatric Hospital, in Almadina Almonawara, KSA. Demographic data including sex, age, marital status, and education level of the cases and controls were collected. SD was diagnosed according to the DSM-IV-TR, whereas PDs were measured using the Diagnostic Checklist for Personality Disorders.
The ages of cases ranged from 32 to 50 years (mean: 39.21±6.45 years); 55.8% of the group was male and 67.3% was married; 924.2% of the participants were educated. There was no significant difference in sociodemographic characteristics. The incidence of PDs in SD patients was 63.3%, compared with 10% in controls [odds ratio (OR)=18.5294; 95% confidence interval (95% CI)=5.6686–60.5687]. The highest OR for PDs in patients with SD, compared with that in controls, was for paranoid personality (OR=18.2063; 95% CI=4.9595–66.8357), followed by obsessive personality (OR=16.5000; 95% CI=5.8373–46.6399), and histrionic personality (OR=9.0444; 95% CI=2.4677–33.1489).
PDs in Saudi SD patients is very high. The results were comparable to that found in British and American studies, supporting the theory of Lillienfield that SD should be grouped under Axis II disorders of the DSM system and not under Axis I. Paranoid, obsessive, and histrionic personalities were the most common PD subtypes in SD patients as regards ORs.
Keywords: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, revision, somatization disorders, personality disorder schedule, personality disorders
|How to cite this article:|
Elsaied HF, Hamed RA, Belay Y. A study of personality disorders among patients with somatization disorder. Egypt J Psychiatr 2017;38:138-42
|How to cite this URL:|
Elsaied HF, Hamed RA, Belay Y. A study of personality disorders among patients with somatization disorder. Egypt J Psychiatr [serial online] 2017 [cited 2018 Jun 23];38:138-42. Available from: http://new.ejpsy.eg.net/text.asp?2017/38/3/138/217205
| Introduction|| |
Somatization disorder (SD) is a form of mental illness that is characterized by chronic, multiple, unexplained somatic complaints, and is sometimes referred to as a functional somatic complaint (Chakraborty et al., 2010; Chakraborty et al., 2012).
Somatic symptoms may be influenced by ethnic factors. For example, SD is very common among South Americans (Aragona et al., 2008, 2012) as well as in Asian people, especially among those suffering from depression, regardless of their age (Suen and Tusaie, 2004). Ethnic factors also influence the type of symptoms reported by patients. For example, Asian patients more frequently complain of a ‘heavy head’ compared with Americans, Caucasians, and Africans (Aragona et al., 2008).
Many studies have confirmed that personality disorders (PDs) and SD are strongly associated with each other, and both appear early in patients (Alnaes and Torgensen, 1988; Rost et al., 1992; Stern et al., 1993). This observation led several authors to consider SD as a form of PD and suggests that it should be included under the title of Axis II, not as Axis I in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Bass and Murphy, 1995).
Some authors documented that somatic symptoms may be related to neuroticism (Klimowicz, 2003) and alexithymia (Sifneos, 1996; De Gucht, 2003), which are personality traits.
Neuroticism is sometimes called ‘emotional instability’, ‘inverse emotional stability’, or ‘negative affectivity’. It is the tendency to see distressing thoughts easily, such as anxiety, depressive disorder, frustration, or susceptibility.
Neuroticism has been considered one of the strongest predictors of somatization (Klimowicz, 2003).
According to these results, somatization could be considered a defense mechanism against internal conflict that the patients find difficult to express directly (Monsen and Havik, 2001; Sar et al., 2004).
The aim of this study was to identify the distribution of all DSM-IV-TR personality disorders among patients with SD who were referred from primary care settings.
| Patients and methods|| |
This case–control study was conducted from September 2014 to April 2015 and was approved by the Ethics Committee at Al Amal Psychiatric Hospital, in Almadina Almonawara, KSA.
Fifty-two consecutive SD patients referred from primary care settings and an age, sex, and education-matched control group of 40 normal participants were selected.
All patients with psychotic illness, including bipolar affective disorder and with organic brain syndromes, were excluded from the study.
Demographic data on sex, age, marital status, and education of the participants were obtained. The diagnosis of the cases was done through clinical interview with the patient and according to the criteria of DSM-IV-TR of SD.
PDs were measured using the Diagnostic Checklist of Personality Disorders, designed by Rashad (1997), with which patients were checked for the presence of PDs using a validated and reliable questionnaire designed to suit Saudi Arabian culture (Rashad, 1997).
In this study, descriptive statistics were examined across all variables. The χ2-test was performed for comparing qualitative variables. Statistical significance was set at P-values less than 0.05.
Odds ratio (OR) was calculated. The SPSS 12 statistical package (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis.
| Results|| |
The age range of the cases was 32–50 years (mean: 39.21±6.45 years); 55.8% of them were male and 67.3% were married; 94.2% of the participants were educated. There were no significant differences between cases and controls in terms of sociodemographic data ([Table 1]).
The incidence of PDs in SD patients was 63.3%, compared with 10% in controls [OR=18.5294; 95% confidence interval (CI)=5.6686–60.5687].
Paranoid personality had the highest OR among PDs in patients, compared with controls (OR=18.2063; 95% CI=4.9595–66.8357), followed by obsessive personality (OR=16.5000; 95% CI=5.8373–46.6399) and histrionic personality (OR=9.0444; 95% CI=2.4677–33.1489) ([Table 2]).
|Table 2: Personality disorders among somatization disorder patients (n=52) and controls (n=40)|
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| Discussion|| |
Many studies documented that PDs and SDs are strongly associated with each other and appear early in the history of the patient (Alnaes and Torgensen, 1988; Rost et al., 1992; Stern et al., 1993).
The current study is a case–control one carried out on 52 consecutive SD patients who were referred from primary care settings.
The age range of the participants was between 32 and 50 years (mean: 39.21±6.45 years); 55.8% of them were male and 67.3% were married; 94.2% of them were educated.
There were no significant differences in sociodemographic data.
This study revealed that the prevalence of PDs among SD patients was 63.3%, which was similar to the finding in other studies on the same subject (Garcia-Campayo et al., 2007).
The prevalence of PDs among SD patients was 62.9%. In the study by Rost et al. (1992), the prevalence was 61% and more than half of them (37.2%) had two or more PDs. In the study by Alnaes and Torgensen (1988), the prevalence was 64%, and in Stern et al. (1993) the prevalence was 72%.
As can be seen, the presence of PD among patients with SD was very high, with comparable results in all of the above-mentioned studies, supporting the theory of Bass and Murphy (1995) that SD should be grouped under Axis II rather than under Axis I.
In our study the prevalence of PDs in the control group was 10%, which is lower than that in the study by Stern et al. (1993) (36%). This can be attributed to the differences in the selected controls. Our control group consisted of normal participants, whereas in other studies the controls consisted of attendants of psychiatric outpatient clinics.
From a methodological point of view, the OR for every PD, compared with that of the control population, is more important than simple frequency. This could be determined in this study because it was a case–control study.
Paranoid personality had the highest OR among PDs in SD patients, compared with controls (OR=18.2063; 95% CI=4.9595–66.8357), followed by obsessive personality (OR=16.5000; 95% CI=5.8373–46.6399) and histrionic personality (OR=9.0444; 95% CI=2.4677–33.1489) ([Table 2]). In the study by Rashad (1997), the highest OR was similar to ours, with paranoid personality showing an OR of 9.2, obsessive–compulsive showing an OR of 6.2, and histrionic personality showing an OR of 3.6. In the study by Stern and colleagues, the highest OR was for passive-dependent (OR=17), followed by sensitive–aggressive (OR=13.7) and histrionic (OR=7.5) personality. In contrast, one of the earliest studies (Kaminsky and Slavney, 1983) that examined traits other than the categories of PDs among patients with SD found that the most common trait in patients with SD was histrionism. The same study (Kaminsky and Slavney, 1983) also showed that obsessive traits were very common.
Another study on somatizing patients referred from primary care observed the same results (Noyes et al., 2001). In our study, obsessive PD showed the second highest OR in SD patients compared with the control group.
Kaminsky and Slavney (1983) observed that the presence of histrionic and obsessive traits may be contributing factors to the diagnosis of SD over time and its resistance to treatment.
Finally, there is a theory called classical Lillienfield assumption (Lillienfield, 1992) that suggests that histrionic and antisocial PDs share the same hereditary diathesis as SD. However, in the above-mentioned study, this fact could not be exclusively confirmed for antisocial PD but was confirmed for histrionic PD.
| Conclusion|| |
The results on PDs in Saudi SD patients matched those found in British and American studies and support the theory of Lillienfield (1992) that SD should be included under DSM Axis II disorders and not under Axis I.
In our study, the most common PDs among SD patients with regard to ORs were paranoid, obsessive, and histrionic personality.
Further research is needed to augment these data in other cultures and in other categories of somatoform disorders rather than SD. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alnaes R, Torgensen S (1988). The relationship between DSM-III symptom disorders (Axis I) and personality disorders (Axis II) in an outpatient population. Acta Psychiatr Scand 78:485–492.
Aragona M, Monteduro DM, Colosimo F, Maisano B, Geraci S (2008). Effect of gender and marital status on somatization symptoms of immigrants from various ethnic groups attending a primary care service. Ger J Psychiatr 11:64–72.
Aragona M, Rovetta E, Pucci D, Spoto J, Villa AM (2012). Somatization in a primary care service for immigrants. Ethn Health 17:477–491.
Bass C, Murphy M (1995). Somatoform and personality disorders: syndromal comorbidity and overlapping developmental pathways. J Psychosom Res 39:403–427.
Chakraborty K, Avasthi A, Grover S, Kumar S (2010). Functional somatic complaints in depression: an overview. Asian J Psychiatr 3:99–107.
Chakraborty K, Avasthi A, Kumar S, Grover S (2012). Psychological and clinical correlates of functional somatic complaints in depression. Int J Soc Psychiatry 58:87–95.
De Gucht V (2003). Stability of neuroticism and alexithymia in somatization. Compr Psychiatry 44:466–471.
Garcia-Campayo J, Alda M, Sobradiel N, Olivan B, Pascual A (2007). Personality disorders in somatization disorder patients: a controlled study in Spain. J Psychosom Res 62:675–680.
Kaminsky MJ, Slavney MJ (1983). Hysterical and obsessional features in patients with Briquet’s syndrome (somatization disorder). Psychol Med 13:111–120.
Klimowicz A (2003). Comparison of the personality of anxiety disorder patients and somatization disorder patients before and after psychotherapy [Article in Polish]. Psychiatr Pol 37:235–246.
Lillienfield SO (1992). The association between antisocial personality and somatization disorders. A review and integration of theoretical models. Clin Psychol Rev 12:641–662.
Monsen K, Havik O (2001). Psychological functioning and bodily conditions in patients with pain disorder associated with psychological factors. Br J Med Psychol 74(Pt 2):183–195.
Noyes R, Langbehn DR, Happel RL, Stout LR, Muller BA, Longley SL (2001). Personality dysfunction among somatizing patients. Psychosomatics 42:320–329.
Rashad M (1997). Diagnostic Checklist of Personality Disorders. Anglo Egyptian Liberary.
Rost KM, Akins RN, Brown FW (1992). The comorbidity of DSM-III-R personality disorders in somatization disorder. Gen Hosp Psychiatry 14:322–326.
Sar V, Akyüz G, Kundakçi T, Kiziltan E, Dogan O (2004). Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. Am J Psychiatry 161:2271–2276.
Sifneos PE (1996). Alexithymia: past and present. Am J Psychiatry 153 (Suppl 7):137–142.
Stern J, Murphy M, Bass C. Personality disorders in patients with somatization disorder: a controlled study. Br J Psychiatry 1993; 163:785–789.
Suen LJ, Tusaie K (2004). Is somatization a significant depressive symptom in older Taiwanese Americans? Geriatr Nurs 25:157–163.
[Table 1], [Table 2]