Suicidality in patients with somatoform disorder – the speechless expression of anger?
Introduction
Patients suffering from medically unexplained symptoms (MUS) and somatoform disorders are common, and adequate diagnostics and therapy still remain challenging (Creed and Barsky, 2004, Haller et al., 2015, Hartman et al., 2009). Patients as well as practitioners often focus on excluding somatic etiologies which causes high costs and undervalues mental aspects and their therapeutic implications. In general, patients diagnosed with somatoform disorders show high rates of psychiatric comorbidities, especially of depression and anxiety disorders (de Waal et al., 2004, Henningsen et al., 2003, Löwe et al., 2008, Mergl et al., 2007), and are likely to have a large disease burden and quality of life decrements (Mack et al., 2015).
So far, only few studies have tried to investigate the severity of courses, outcome, and associated aspects such as self-harm or suicidality in patients with MUS or somatoform disorders. A recent study by Park et al. (2012) revealed elevated suicidality (ideation, plans, attempts) in patients suffering from medically unexplained. Several researchers also have postulated elevated suicidality in patients with somatoform disorders (Chioqueta and Stiles, 2004, Morrison and Herbstein, 1988, Purtell et al., 1951, Woodruff et al., 1972). Recently, Klerk et al. (2011) investigated psychiatric outpatients and found that 45% of 461 somatoform disorder patients reported lifetime deliberate self-harm or current self-harm and suicidal ideation. It should be mentioned that their findings were not corrected for psychiatric comorbidities. Furthermore, the association between suicidality and somatoform complaints was found in psychiatric outpatients and also in primary care patients who visited general practitioners (Wiborg et al., 2013a, Wiborg et al., 2013b), indicating a considerable relevance for everyday clinical practice. Wiborg et al. (2013a) revealed high suicidality rates in these primary care patients diagnosed with somatoform disorders: 37% of them reported current thoughts of wishing they were dead or hurting themselves, 24% showed active suicidal thoughts during the six months preceding the survey, and 18% had suicide attempts in the prolonged past. Comorbid severe depression was significantly higher in patients with suicidal ideation. The authors also showed that dysfunctional illness perceptions in somatoform disorder patients were associated with suicidal ideation and therefore assumed that specific cognitive processes might play an important role in developing suicidal ideation, irrespective of comorbid depression.
According to these findings, suicidality is an underestimated problem in somatoform disorders. This is mirrored in a lack of studies investigating predictors and specific risk factors, apart from the influence of comorbid depression or other psychiatric diagnoses.
Several authors who have investigated suicidality in psychiatric patients with other diagnoses than somatoform disorders revealed specific emotions (e.g. anger) to be associated with suicidality (e.g. Daniel et al., 2009; Evren et al., 2011; Giegling et al., 2009; Horesh et al., 1997). In addition to general risk factors, such as previous suicide attempts and certain sociodemographic factors, a current review about suicide and associated risk factors (Turecki and Brent, 2015) underlines the relevance of specific emotions (e.g. aggression, anxiety) and personality-based competences in affective regulation. The authors assumed that in addition to ‘distal/predisposing’ risk factors (e.g. genetics, early-life adversity) and ‘proximal/precipitating’ risk factors (e.g. current life events, psychopathologies, substance misuse), personality traits and cognitive styles could be seen as ‘developmental’ or ‘mediating’ risk factors for suicidality.
Somatoform disorders are considered to be closely linked to deviant emotion perception and deficits in affect regulation (e.g. van Dijke and Ford, 2015; Waller and Scheidt, 2006), and research has shown that the amount of anger correlates with chronic pain (Castelli et al., 2013, Greenwood et al., 2003, Sayar et al., 2004, Trost et al., 2012;). Regarding the above mentioned role of anger and aggression in suicidal patients, it seems a promising approach to focus on these aspects in the examination of specific suicidality predictors in suicidal somatoform disorder patients.
Interestingly, several authors have emphasized an important connection between personality-based difficulties in identifying and verbalizing emotions, for which Nemiah and Sifneos coined the term alexithymia (Nemiah and Sifneos, 1970; Sifneos, 1973; Taylor, 2000a; Taylor et al., 1991), and somatoform disorders (e.g. Burba et al., 2006; Cox et al., 1994; de Gucht and Heiser, 2003; Koelen et al., 2015; Mattila et al., 2008; Waller and Scheidt, 2006). Recent research has found increasing evidence for a positive association between alexithymia and suicidality. Thus, Hintikka et al. (2004) showed in a general population sample alexithymia to be associated with the presence of suicidal ideation even after adjustment for several psychosocial factors and depression. Other studies have revealed a positive correlation between alexithymia and suicidality in the subsequent psychiatric subpopulations: patients with alcoholism (Sakuraba et al., 2005), eating disorders (Alpaslan et al., 2015, Carano et al., 2012), panic disorder (Iancu et al., 2001), generalized anxiety disorder (Berardis et al., 2015), post-traumatic stress disorder (Kušević et al., 2015), and schizophrenia (Marasco et al., 2011). However, this relationship has not been investigated in somatoform disorder patients.
Against this backdrop, the aim of this study was to investigate possible associations between suicidality and difficulties in identifying emotions and coping with anger in patients with somatoform disorders. We hypothesize that somatoform disorder patients with lifetime suicide attempts show higher general distress and alexithymia levels and differ in anger experience and management from patients without lifetime suicide attempts.
Section snippets
Sample
A sample of 155 consecutive outpatients diagnosed with somatoform disorders at the Psychosomatic Ambulance of Bonn University Hospital was enrolled in this study. Recruitment and data collection were conducted from January 2013 until July 2015. The study was approved by the local ethics committee and informed consent was obtained from all subjects. Patients were diagnosed by experienced clinical experts at the Clinic for Psychosomatic Medicine and Psychotherapy, University of Bonn, Germany.
Of
Sample characteristics and socio-demographic data
The mean age of patients enrolled in this study was 42.18 years (SD=15.72) with a range from 17 to 79 years. The sample consisted of 57.4% females. The mean of duration of somatic complaints was 8.4 years (SD=9.38) and of mental complaints 8.2 years (SD=9.71). Between the two subgroups (presence or absence of lifetime suicide attempts), there was no significant difference concerning age, sex, comorbid depression, anxiety disorder, and borderline personality disorder. There were significant
Elevated suicidality in somatoform disorder patients
The aim of this study was to investigate possible factors associated with suicidality in patients diagnosed with somatoform disorders. We found that 12.9% of our patients stated at least one suicide attempt in their life. Current active suicidal ideation and thoughts of death or dying were elevated and significantly more frequent in the subgroup of suicide attempters. These findings are in line with the revealed elevated suicidality in patients with somatoform disorders by Wiborg et al. (2013a)
Summary
In this study somatoform disorder patients with lifetime suicide attempts show greater difficulties in identifying and describing emotions and show a personality-based tendency to intensely experience and express anger. The evaluation of individual anger regulation and alexithymia should be considered to be included in the initial diagnostic assessment to optimize the identification of patients at risk for suicidal behaviour. Aspects of anger management should then be involved in treatment
Conflicts of interest
None.
Disclosure statement
The authors have nothing to disclose.
Acknowledgements
None.
References (82)
- et al.
Disordered eating attitudes, alexithymia and suicide probability among Turkish high school girls
Psychiatry Res.
(2015) - et al.
The twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure
J. Psychosom. Res.
(1994) - et al.
The twenty-item Toronto Alexithymia Scale--II. Convergent, discriminant, and concurrent validity
J. Psychosom. Res.
(1994) - et al.
Alexithymia, temperament and character as predictors of psychopathology in patients with major depression
Psychiatry Res.
(2009) - et al.
Alexithymia in somatoform disorder patients with chronic pain
J. Psychosom. Res.
(1994) - et al.
A systematic review of the epidemiology of somatisation disorder and hypochondriasis
J. Psychosom. Res.
(2004) - et al.
Alexithymia and somatisation: quantitative review of the literature
J. Psychosom. Res.
(2003) - et al.
History of suicide attempt in male substance-dependent inpatients and relationship to borderline personality features, anger, hostility and aggression
Psychiatry Res.
(2011) - et al.
The prevalence of somatoform disorders among internal medical inpatients
J. Psychosom. Res.
(2004) - et al.
The effects of mindfulness-based treatments for aggression: a critical review
Aggress. Violent Behav.
(2013)
Personality and attempted suicide. Analysis of anger, aggression and impulsivity
J. Psychiatr. Res.
Anger and persistent pain: current status and future directions
Pain
Alexithymia and suicidal ideation: a 12-month follow-up study in a general population
Compr. Psychiatry
Alexithymia and suicidality in panic disorder
Compr. Psychiatry
The assessment of alexithymia: a critical review of the literature and a psychometric study of the Toronto Alexithymia Scale- 20
J. Psychosom. Res.
Identifying somatization disorder in a population-based health examination survey: psychosocial burden and gender differences
Psychosomatics
Affective agnosia: expansion of the alexithymia construct and a new opportunity to integrate and extend Freud’s legacy
Neurosci. Biobehav. Rev.
Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study
Am. J. Med.
Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment
Gen. Hosp. Psychiatry
Functional disability and quality of life decrements in mental disorders: results from the Mental Health Module of the German Health Interview and Examination Survey for Adults (DEGS1-MH)
Eur. Psychiatry.: J. Assoc. Eur. Psychiatr.
Secondary affective disorder in women with somatization disorder
Compr. Psychiatry
Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial
Behav. Res. Ther.
Treatment of aggression with topiramate in male borderline patients, part II: 18-month follow-up
Eur. Psychiatry
Psychiatric morbidities, sleep disturbances, suicidality, and quality-of-life in a community population with medically unexplained pain in Korea
Psychiatry Res.
Childhood physical abuse, aggression, and suicide attempts among criminal offenders
Psychiatry Res.
The alexithymia construct. A potential paradigm for psychosomatic medicine
Psychosomatics
Alexithymia and self-directedness as predictors of psychopathology and psychotherapeutic treatment outcome
Compr. Psychiatry
Cognitive dimensions of anger in chronic pain
Pain
Suicidal ideation in German primary care
Gen. Hosp. Psychiatry
Validierung der deutschen Version der 20-Item Toronto-Alexithymie-Skala bei Normalpersonen und psychiatrischen Patienten
Psychother. Psychosom. Med. Psychol.
The amplification of somatic symptoms
Psychosom. Med.
Gender differences in prevalence of somatoform disorders in patients visiting primary care centers
J. Prim. Care Community Health
Alexithymia, suicide ideation, C-reactive protein and serum lipid levels among outpatients with generalized Anxiety Disorder
Arch. Suicide Res.: Off. J. Int. Acad. Suicide Res.
Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review
Acta Psychiatr. Scand.
A controlled study of alexithymia in adolescent patients with persistent somatoform pain disorder
Can. J. Psychiatry Rev. Can. Psychiatr.
Alexithymia and suicide ideation in a sample of patients with binge eating disorder
J. Psychiatr. Pract.
Alexithymia, anger and psychological distress in patients with myofascial pain: a case-control study
Front. Psychol.
Psychological and clinical correlates of functional somatic complaints in depression
Int. J. Soc. Psychiatry
Suicide risk in patients with somatization disorder
Crisis
Trait anger, anger expression, and suicide attempts among adolescents and young adults: a prospective study
J. Clin. Child Adolesc. Psychol.: Off. J. Soc. Clin. Child Adolesc. Psychol. Am. Psychol. Assoc. Div. 53
Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders
Br. J. Psychiatry.: J. Ment. Sci.
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