Objective: The somatic component of depression is an important clinical ... Scale, the Beck Anxiety Scale, the Hamilton Depression. Scale, the Hamilton Anxiety ...
Türk Psikiyatri Dergisi 2005; 16(2) Turkish Journal of Psychiatry
Somatic Symptoms of Depression Hüseyin GÜLEÇ, Kemal SAYAR, Evrim ÖZKORUMAK
INTRODUCTION SUMMARY: Somatic Symptoms of Depression
The relation between depressive disorder and somatization has been known for years (Lipowski 1988). This concurrence has been found to be high in epidemiological and clinical studies (Bridges and Goldberg 1985, Blacker and Clare 1987). Kirmayer reported that depression had been commonly somatized (1984). Kesebir summarized views about the relation between somatization and depression as follows: 1- they are equivalent; 2somatization is a special and specific subtype of depression and anxiety; and 3-somatization is the basic characteristic of depression (2004). Lipowski proposed that depression could lead to somatization symptoms by recalling previous disease history as a consequence of regression (1990).
Objective: The somatic component of depression is an important clinical phenomenon. The role of somatic amplification, alexithymia, anger and symptom attribution has been investigated in the genesis of the somatic symptoms of depression. Method: The study was carried out with 32 patients attending the outpatient psychiatry clinics of Karadeniz Technical University Medical School, meeting the diagnosis of depression according to DSM-IV, and 34 healthy subjects. The subjects were assessed with the Beck Depression Scale, the Beck Anxiety Scale, the Hamilton Depression Scale, the Hamilton Anxiety Scale, the Somatosensory Amplification Scale, the 20-item Toronto Alexithymia Scale the Spielberger State-Trait Anger Expression Inventory, the Symptom Interpretation Questionnaire and a data form for recording sociodemographic characteristics.
Somatization which is accepted as a conflicting factor in diagnosis of depression is closely related with how someone interprets somatic sensations attributes what causes them (Duman et al. 2004). Robbins and Kirmayer claimed that individuals normalized ordinary somatic symptoms by attributing them to states like insomnia, tiredness or excessive noise or perceived them as psychological or somatic abnormalities (1991). They proposed that causative attributes were determined by choicing between somatic, psychological and normalizing explanations. Somatic symptoms which might be considered as an expression of psychological distress can lead to unnecessary medical evaluation or malpractice (Kirmayer 2001). In the study of 305 patients from primary health care units, Kessler and colleagues found that physicians did not consider normalization attributes significant, but this attitude might lead underestimation of depression and anxiety (1999). They showed that normalizing
Results: The sociodemographic characteristics of the sample were similar. The anxiety, alexithymia, and angerin scores were significantly higher, while anger-control scores were significantly lower in the depressive subjects. Psychologizing attributes were positively correlated with depression and anxiety. Normalizing was negatively correlated with anxiety. Somatizating was correlated with the difficulty in identifying feelings subscale of alexithymia. Discussion: These findings show that depressive patients are more alexithymic, have more difficulty in controlling their anger and introject their anger more compared to the healthy controls. Depressed and anxious subjects psychologize, and subjects with difficulty in identifying emotions somatize their symptoms. Key Words: Depression, amplification, alexithymia, anger
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and psycohologizing attributes were determinants of depression diagnosis. With the effect of this study Bower and colleagues performed another study with a larger sample and found that disease severity of age were determinants of psychiatric disease and using more psycohologizing attributes facilitated recognition of psychiatric diseases by general practitioners.
In this study we considered the hypothesis that causative attribution styles were related with psychological variants like somatosensory amplification, alexithymia and anger. Considering age and level of education as conflicting factors, we limited our sample with university students (Sayar et al. 2003a). With the expectation of somatosensory amplification, alexithymia, anger and expression styles were different in depressive individuals versus healthy controls, our hypothesis were;
It was reported that in depressive individuals negative and pessimistic cognitive schemes causing refreshment of disease memory, formed a background for negative perception of health condition and subsequently sensitized the individual against unpleasant somatic happenings (Barsky and Wyshak 1990). In depression, focusing of patients on their bodies results simple, ordinary feelings to be perceived as severe discomfort. Depression and amplifying somatic sensations were reported to be in close relation (Barsky et al. 1988, Sayar et al. 2003b). Sayar and colleagues reported anxiety, somatosensory amplification and alexithymia as three predictors of somatization symptoms in depressive patients (2003a).
1. There would be a positive relation between psychological attribution and depression or anxiety in depressive patients; 2. Somatosensory amplification, alexithymia, anger and expression styles would be positively correlated with somatizating attribution and negatively correlated with anger control in depressive patients. METHOD Totally 66 individuals, 32 patients (15 females, 17 males; mean age was 23.0±4.8) who admitted to Karadeniz Technical University, Medico-Social Centre, Outpatient Clinics of Psychiatry and consecutively were diagnosed as major depression according to DSM-IV criteria between November 2002 and January 2003 and as control group, 34 healthy volunteers (11 females, 23 males; mean age was 21.9±3.1) from university students who were comparable for age and level of education, were included in the study. Written informed consent was received from all participants. Approval from Ethics Committee of Karadeniz Technical University Faculty of Medicine was received as well.
Parker and colleagues suggested that alexithymia which was once thought to be a distinctive charactheristic of psychosomatic diseases might be an adaptive regression reaction which could be seen in psychiatric disorders like depression. Alexithymia is defined as poverty in imagination besides difficulty in discrimination and recognition of feelings. Inadequate verbal expression of feelings causes somatization. The relation between alexithymia and depression was shown in various studies (Parker et al. 1991, Hendryx et al. 1991). Relying on their study with 20 item Toronto Alexithymia Scale (TAS-20) and Hamilton Depression Rating Scale (HDRS), Honkalampi and colleagues claimed that alexithymia and depression were different, but closely related situations.
All patients with psychiatric complaints were evaluated with Structured Clinical Interview Scale (SCID-I, Spitzer et al. 1987, Sorias et al. 1990). Patients with mental retardation, demantia, cognitive disorder, psychotic disorder, history of other medical illnesses or psychotropic drug use were not included. There were 7 of 39 interviewed patients who did not accept participation.
Anger and its expression are important aspects of depression and somatization. Anger was evaluated as a negative affect ranged from mild irritation to hate and violence which was a consequence of sensational, cognitive and experience of behavioral style. Koh defined anger and supressed hostility as an important factor in development of somatization (2003). According to the type of expression, it was reported that somatization was due to extraversion of anger in depression and supression of anger in anxiety (Koh 2003).
Clinical interviews were performed by a fourth year resident of Psychiatry who had education on SCID-I. Diagnoses were confirmed with a second interview by a specialist. Sociodemographic data Sociodemographic and medical data were re-
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TABLE 1. Sociodemographic Comparison of the Groups
Age
Normal Healthy Group (n=34)
Patients (n=32)
Mean ± standard deviation
Mean ± standard deviation
t
p
21.9±3.1
23.0±4.8
1.040
AD
13.6±1.8
13.5±1.9
0.327
AD
χ2 1.456
AD
0.433
AD
0.385
AD
10.170
0.006
0.026
AD
0.283
AD
Duration of Education n
%
n
%
Female Male
11
32.4
15
46.9
23
67.6
17
53.1
Yes No
5 29
14.7 85.3
3 29
9.4 90.6
Residency City Small town Village
21 10 3
61.8 29.4 8.8
22 8 2
68.8 25.0 6.3
Childhood Residency City Small town Village
21 13
61.8 38.2
17 8 7
53.1 25.0 21.9
Gender
Married
Concurrent Illness Absent Present
26 8
76.5 23.5
25 7
78.1 21.9
Suicidal Attempt Present Absent
32 2
94.1 5.9
29 3
90.6 9.4
ceived from a questionnaire which was completed by the participant. Gender, age, level of education, marital status, places of residency and childhood, presence of suicidal attempt, concurrent illnesses and family history for psychiatric disorders were asked in the questionnaire.
ween 0-3 and includes 21 items. Total point increases with the severity of anxiety. It was developed by Beck and colleagues (1988) and validity and reliability studies in our country was performed by Ulusoy and colleagues (1998). Hamilton Depression Rating Scale (HDRS): This scale was developed by Hamilton in 1960. It measures the level of depression and includes 17 questions. Maximum point is 53. Points equal to or above 14 indicate depression. Turkish validity and reliability study was performed by Akdemir and colleagues (1996).
Clinical evaluation Beck Depression Inventory (BDI): Somatic, sensorial and cognitive symptoms of depression are evaluated with this scale. It is a self assessing scale which includes 21 symptom categories. Maximum point to be received is 63. Total point increases with the severity of depression. It was developed by Beck and colleagues (1961) and validity and reliability studies in our country was performed by Hisli (1988).
Hamilton Anxiety Scale (HAS): This scale which was developed by Hamilton in 1959 determines level of anxiety and symptom distribution and measures changes in severity in individuals. It includes 14 items directed to evaluate mental and somatic symptoms both. Interviewer evaluates the presence and severity of the items. Turkish validity
Beck Anxiety Inventory (BAI): This scale evaluates the frequency of anxiety symptoms. It is a self assessing, Likert type scale which is rated bet-
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Statistical Analysis
and reliability study was performed by Yazıcı and colleagues (1998).
Consistency of measured data with normal distribution was evaluated with Kolmogorov Smirnov test for each group. Analysis of data was realized with student t-test for normally distributed results and Mann-Whitney-U-test for others. Correlation analyses were performed with Pearson and Spearman methods.
Somatosensory Amplification Scale (SSAS): This scale questions whether the individual amplifies normal somatic sensations. It is a self assessing, Likert type scale which is rated between 1-5 and includes 10 items. Total point is evaluated as the point of amplification. It was developed by Barsky and colleagues (1988) in order to explain somatization. Turkish validity and reliability studies was performed by Sayar and colleagues (2003c).
Analysis of counted data was performed with chi-square test (when the expected value was below 5, Fisher’s exact test was used). Measurements were expressed as mean ± standard deviation and counted values were expressed as percentage. Level of significance was accepted as p0.05). Ratio for living in cities during childhood was higher among depressive individuals (χ2=10.174, df=2, p=0.006). Family history for psychiatric disorders item was not taken into consideration because of defective answering.
Spielberger State-Trait Anger Expression Inventory (SSTAEI): This scale measures the feeling and expression of anger. It is a self assessing scale which includes 34 items. Ten items evaluate continuous anger and 24 items evaluate expression of anger. Studies of state anger subscale have not been completed yet. Style of anger expression includes three subscales; anger-in (8 items), angerout (8 items) and anger control (8 items). It was developed by Spielberger (1983) and Turkish validity and reliability studies was performed by Özer (1994).
When levels of depression, anxiety and somatosensory amplification were compared between groups self assessment and clinical evaluated depression (t=10.172, df=50.592, p0.001 respectively) and anxiety (z=4.179, p0.05). Total alexithymia points of depressive group were higher (t=3.431, df=71, p=0.001).
Symptom Interpretation Questionnaire (SIQ): This questionnaire evaluates the attribution which individuals use in interpreting widespread somatic symptoms. Thirteen somatic symptoms are asked for attribution to a physical disease (somatization), psychiatric disease (psychologization) or normal environmental stimuli (normalization) with severity ratings. It was developed by Robbins and Kirmayer (1991) and Turkish validity and reliability studies was performed by Güleç and Sayar (2004).
When anger structures of the groups were compared, continuous anger subscale and anger-out points were statistically similar, but anger-in and anger-control points were higher in depressive
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group (t=3.431, df=71, p=0.001; t=2.999, df=71, p=0.004, respectively).
are conflicting. We found levels of idetifying and expression of feelings lower in depressive group than controls. Two groups were not different in operational thought subtest. Depressive group had significantly higher total points for alexithymia.
When SIQ points of two groups were compared, somatic attribution subscale points of depressive group were higher, but the difference was not significant. The points of all subscales were not different statistically (p>0.05).
There are some studies which reveal that angerin structuring is more prominent in depression (Riley et al. 1989). When individuals recovered from depression were compared with others who never had a depressive episode, it was shown that two groups were similar for anger expression, but anger suppression style was still in use in recovered group (Brody et al. 1999). We found anger-in points higher in depressive group as previous studies. Anger control points were expected to be higher in depression, but we did not observe such findings. Anger suppression was shown to be high in the literature. Our finding about depression development not only in anger suppression, but in inadequate anger control as well needs to be supported with further studies.
When relations between psychological variants were taken into consideration, there were positive correlations between psychological attribution subscale and depression and anxiety (r=0.48, p=0.006; r=041, p=0.020, respectively), somatic attribution subscale and difficulty in identifying feelings (r=0.42, p=0.017), normalizing attribution and anxiety (r=0.46, p=0.008). Depression levels of self assessment and interviewer evaluated scales were strongly correlated (r=0.74, p0.05). DISCUSSION
When attribution of symptoms was evaluated by means of SIQ, it was shown that depressive group did not tended to interpret symptoms by attributing to anything. The relation between psychological attribution and levels of anxiety or depression was found to be low. Relatively low level of somatic attribution despite high levels of alexithymia in depressive group may be due to age and educational level of the group.
This study was planned in order to better evaluate somatization concept which might have influence on clinical aspect of depression. Depression group and controls were found to be similar according to sociodemographic characteristics. Barsky explained somatization as exaggerated and distorted perception of somatosensory inputs during processing at cortex in his amplification theory (1992). This condition was reported to be continuous in somatization, but case specific in depression and amplification was told to measure negative affect and generalized distress (Barsky et al. 1988). Barsky and colleagues reported a strong (1988), but Muramatsu and colleagues reported a weak (2002) relation between amplification and depression. We did not find any relation between these two entities. Amplification points of depressive group were not different from controls. Sayar and colleagues showed that somatization in depression was positively predicted by amplification and negatively predicted by educational level (2003a). This observation may explain relatively low level of amplification as our study group was made up of university students.
As a conclusion, we found high alexithymia and anger-in levels but low anger control levels in depression patients. Psychological attribution was positively correlated with both depression and anxiety, but normalizing attribution was negatively correlated with the level of anxiety. Somatic attribution was related with difficulty in identifying of feelings. There is no doubt that comparison of our findings with depressive patients from different age groups and educational levels will provide additional benefit.
Göka considered alexithymia as a characteristic which provided qualified and scientific information in either philosophy or neuroscience because of its role in brain-body intervention (1999). Studies about concurrence of depression and alexithymia
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REFERENCES
Koh KB (2003) Anger and somatization. J Psychosom Res, 55(2):113.
Akdemir A, Örsel S, Dağ İ et al (1996) Hamilton depresyon derecelendirme ölçeği (HDDÖ)’nin geçerliliği, güvenilirliği ve klinikte kullanımı. Psikiyatri Psikoloji Psikofarmakoloji Dergisi, 4:251-9.
Lipowski ZJ (1988) Somatization: The Concept and Its Clinical Application. Am J Psychiatry, 145(11):1358-68. Lipowski ZJ (1990) Somatization and depression. Psychosomatics, 31:13-21.
Aydemir Ö, Danacı AE, Taşkın O et al (2000) Aleksitimik hastalarda depresyon ölçümü: Kendini bildirim ölçeğine karşılık görüşmecinin değerlendirdiği ölçek. Türk Psikiyatri Dergisi, 11(2):127-30.
Muramatsu K, Miyaoka H, Muramatsu Y et al (2002) The amplification of somatic symptoms in upper respiratory tract infections. Gen Hosp Psychiatry, 24(3):172-5.
Bagby RM, Parker JD, Taylor GJ (1994) The twenty-item Toronto Alexithymia Scale-I Item selection and cross-validation of the factor structure. J Psychosom Res, 38(1):23-32.
Özer AK (1994) Sürekli Öfke ve Öfke İfade Tarzı Ölçekleri Ön Çalışması. Türk Psikoloji Dergisi, 9:31:26-35. Parker JD, Bagby RM, Taylor GJ (1991) Alexithymia and depression: distinct or overlapping constructs? Compr Psychiatry, 32(5):387-94.
Barsky AJ, Goodson JD, Lane RS (1988) The amplification of somatic symptoms. Psychosom Med, 50:510-19. Barsky AJ, Wyshak G (1990) Hypochondriasis and somatosensory amplification. Br J Psychiatry, 157:404-9.
Riley WT, Treiber FA, Woods MG (1989) Anger and hostility in depression. J. Nerv Ment Dis, 177:668-74.
Barsky AJ (1992) Amplification, somatization and the somatoform disorders. Psychosomatics, 33:28-34.
Robbins JM, Kirmayer LJ (1991) Attributions of common somatics symptoms. Psychol Med, 21:1029-45.
Beck AT, Epstein N, Brown G et al (1988) An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol, 56:893-897.
Sayar K, Güleç H, Ak İ (2001) Yirmi soruluk Toronto Aleksitimi Ölçeği’nin geçerlik ve güvenirliği. 37. Ulusal Psikiyatri Kongresi Kitabı, 02-06 Ekim 2001, İstanbul, s.130.
Beck AT (1961) An inventory for measuring depression. Arch Gen Psychiatry, 4:561-71.
Sayar K, Kirmayer LJ, Taillefer S (2003a) Predictors of somatic symptoms in depressive disorder. Gen Hosp Psychiatry, 25:108-14.
Blacker CVR, Clare AW (1987) Depressive disorder in primary care. Br J Psychiatry, 50:737-51.
Sayar K, Güleç H, Topbaş M, et al (2003b) Bedensel Duyumlar Antidepresan Tedaviyle Azalır mı? 39. Ulusal Psikiyatri Kongresi Kitabı, 14-19 Ekim 2003, Antalya, s.659.
Bower P, West R, Tyleec A et al (2000) Symptom attribution and the recognition of psychiatric morbidity. J Psychosom Res, 48:15760.
Sayar K, Güleç H, Topbaş M, et al (2003c) Bedensel Duyumları Büyütme Ölçeği’nin Güvenirliği. 39. Ulusal Psikiyatri Kongresi Kitabı, 14-19 Ekim 2003, Antalya, s.660-1.
Bridges RN, Goldberg DP (1985) Somatic presentation of DSMIII psychiatric disorder in primary care. J Psychosom Res, 29:563-9.
Sorias S, Saygılı R, Elbi H et al (1990) DSM-III-R Yapılandırılmış Klinik Görüşmesi Türkçe Versiyonu SCID Kullanma Klavuzu, İzmir, Ege Üniversitesi Yayınları.
Brody CL, Haaga DA, Kirk L, Solomon A (1999) Experiences of anger in people who have recovered from depression and neverdepressed people. J Nerv Ment Dis, 187(7):400-5.
Spielberger CD, Jacobs G, Russel F et al (1983) Assessment of anger: The state trait anger scale. Advances in personality assessment, Cilt II, Butcher JN, Spielberger CD (Eds), LEA, Hillsdale, NJ:s.15987.
Duman OY, Usubutun S, Goka E (2004) Belirti Yorumlama Olçeginin Turkçe Geçerlik ve Güvenirliği. Türk Psikiyatri Dergisi, 15(1):26-40. Göka E (1999) Bir semptom florası ve dil olarak beden, T Klin Psikiyatri,1:7-17.
Spietzer RL, Williams JBW, Gibbon M et al (1987) Structured Clinical Interview For DSM-III-R. Washington DC, American Psychiatric Press.
Güleç H, Sayar K (2004) Semptom Yorumlama Anketinin geçerlik ve güvenirliği. 40. Ulusal Psikiyatri Kongresi Kitabı, 28 Eylül-3 Ekim 2004, Kuşadası, s.283-4.
Ulusoy M, Şahin NH, Erkmen H (1998) Turkish version of the Beck Anxiety Inventory: Psychometric properties. J Cogn Psychother, 12:163-172.
Hamilton M (1959) The assessment of anxiety states by rating. Br J Med Psychol, 32:50-55.
Williams BW (1978) A structured interview guide for Hamilton Depression Rating Scale. Arch Gen Psychiatr, 45:742-7.
Hendryx MS, Haviland MG, Shaw DG (1991) Dimensions of alexithymia and relationship to anxiety and depression. J Pres Assess, 56:227-37.
Yazıcı MK, Demir B, Tanrıverdi N et al (1998) Hamilton Anksiyete Değerlendirme Ölçeği, değerlendiriciler arası güvenirlik ve geçerlilik çalışması. Türk Psikiyatri Dergisi, 9(2):114-7.
Hisli N (1989) Beck Depresyon Envanterinin üniversite öğrencileri için geçerliği, güvenirliği. Psikoloji Dergisi, 7(23):3-13. Honkalampi K, Hintitkka J, Tanskanen A et al (2000) Depression is strongly associated with alexithymia in the general population. J Psychosom Res, 48:99-104. Kesebir S (2004) Depresyon ve Somatizasyon. Klinik Psikiyatri, Ek 1:14-9. Kessler D, Lloyd K, Lewis G et al (1999) Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ, 318:436-40. Kirmayer LJ (1984) Culture, affect and somatization. Trans Psychiatr Res, 21:159-88. Kirmayer LJ (2001) Cultural variations in the clinical presentation of depression and anxiety: implication for diagnosis and treatment. J Clin Psychiatry, 62(Suppl 13):22-8.
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