Somatic preoccupation has been associated with a variety of comorbid psychiatric conditions including childhood trauma, personality disorder, and depression. The current study was undertaken to simultaneously explore the inter-relationship of these psychiatric variables as conceptualized in a path model. Participants (N = 120), both men and women, seen for nonemergent health care in a resident-staffed internal medicine clinic, were given questionnaires exploring the presence of childhood trauma, borderline personality symptomatology, current depression, worry, and somatic preoccupation. With one exception, all simple correlation coefficients among study variables were relatively substantial. By sequencing variables into an a priori model and using a path analytic approach, several indirect and direct relationships among variables were evident. Most important, childhood trauma exhibited a direct effect on somatic preoccupation as well as indirect effects through borderline personality disturbance and current depression. These data suggest that childhood trauma may be a precursor for somatic preoccupation during adulthood.
Somatic preoccupation is a descriptive term that applies to a broad range of heterogeneous patients who report physical complaints without medically confirmed or complementary physical findings (i.e., findings, if present, do not correspond to the degree of complaint). Thus, the term somatic preoccupation might apply to individuals who
1. manifest psychological conflicts in a somatic fashion;
2. have notable psychological factors that accompany or complicate a genuine physical disorder; or
3. have psychophysiologic symptoms in which psychological factors play a major role (Righter & Sansone, 1999).
In clinical practice, the majority of these individuals do not meet DSM-IV (American Psychiatric Association, 1994) criteria for somatoform disorders (i.e., they appear to have subthreshold syndromes; Righter & Sansone, 1999).
The etiology of somatic preoccupation remains unclear, but psychiatric syndromes appear to be concurrent in many cases (Righter & Sansone, 1999). Whether psychiatric syndromes are primary or secondary is unknown. Comorbid psychiatric syndromes include both depression (Kellner, 1991; Lipowski, 1990; Simon, Gator, Kisely, & Piccinelli, 1996) and anxiety (Simon et al., 1996; Spinhoven & van der Does, 1997); early developmental trauma, including sexual (Collett, Cordle, Stewart, & Jagger, 1998; Farley & Keaney, 1997; Morse, Suchman, & Frankel, 1997; Polusny & Follette, 1995) and physical (Badura, Reiter, Altmaier, Rhomberg, & Elas, 1997) abuse (multiple forms of maltreatment appear most predictive; Arnold & Privitera, 1996; Walker, Keegan, Gardner et al., 1997); and personality disorder (Bass & Murphy, 1995; Lipowski, 1990). With regard to the latter, Hudziak and colleagues (1996) found that 25% of patients with borderline personality disorder (BPD) met criteria for somatization disorder. Surprisingly, the relationship between somatic preoccupation and worry, a common accompanying feature of depression, is not well studied.
Among these comorbid psychiatric variables, two hypothetical relationships to somatic preoccupation seem plausible. First, each of these variables may distinguish separate and discrete subsets of patients with somatic preoccupation. In other words, somatic preoccupation may be independently related to each variable.
Second, there may be an inter-relationship among the variables with a possible sequential relationship among some. For these particular variables, the following sequential model of factors seemed most plausible, based upon available research. Childhood trauma would appear to be the initial event in a sequential model. One possible outcome of childhood trauma is borderline personality symptomatology (Zanarini & Frankenburg, 1997). Indeed, numerous researchers have reported associations between BPD and specific types of childhood trauma such as sexual abuse (Bryer, Nelson, Miller, & Kroll, 1987; Fossati, Madeddu, & Maffei, 1999), combined sexual and physical abuse (Brown & Anderson, 1991; Goldman, D'Angelo, DeMaso, & Mezzacappa, 1991; Ogata etal., 1990; Paris, Zweig-Frank, & Gudzer, 1994), and witnessing of serious violence (Herman, Perry, & van der Kolk, 1989; Weaver & Clum, 1993). With the consolidation of BPD, there are distinct affective symptoms which may include chronic dysphoria and anxiety (American Psychiatric Association, 1994; Kolb & Gunderson, 1980; van der Kolk, Hosteller, Herron, & Fisler, 1994). At the end of this possible path is somatic preoccupation in adulthood, which has been previously recognized as a possible outcome among those with sexual or physical abuse (McCauley et al., 1997), mood disorders (Righter & Sansone, 1999), and personality disorder including BPD (Righter & Sansone, 1999). In summary, a plausible sequence of these complex variables might be childhood abuse, then the development of borderline personality, then the subsequent emergence of mood disorders, and finally somatic preoccupation.
The current study was designed to simultaneously explore the relationships between and among childhood trauma, borderline personality symptomatology, acute depression and worry, and somatic preoccupation within a sample of patients from a primary care setting.
Research participants were 34 men and 86 women (N = 120) who presented to an outpatient resident-staffed internal medicine clinic for nonemergent medical care. At the time of registration for the appointment, the receptionist explained the purpose of the project and invited eligible patient candidates (i.e., those age 18 or older, no cognitive impairment, nonemergent medical condition) to participate (i.e., the sample was one of convenience). The elements of informed consent (e.g., voluntary participation, potential risks and benefits of participation, confidentiality) were provided on the cover page of the research booklet and approved by the institutional review boards of both the study site and the university. All participants completed research materials onsite in the waiting area. Completion of materials functioned as informed consent. Of the 137 candidates who were invited to participate, 17 either refused or did not complete materials, for an overall response rate of 87.6%.
Participants ranged in age from 19-54 years (M = 36.03, SD = 8.92). Most were White, Non-Hispanic (90.8%); the remaining participants were African American (9.2%). Most participants (85.0%) had attained at least a high school diploma, with 17.5% reporting a bachelor's degree or higher. The socioeconomic status of participants was not determined.
Childhood Trauma. Given the complexities of assessing childhood trauma, the clinical setting of the study, and the length of the questionnaire booklet, we made a decision to limit the number of questions in this area. Participants were simply asked whether, in childhood, they had experienced sexual abuse (i.e., "any sexual activity against your will"), physical abuse (i.e., "any physical insult against you that would be considered socially inappropriate by either yourself or others and that left visible signs of damage on your body either temporarily or permanently or caused pain that persisted beyond the 'punishment'"), emotional abuse (i.e., "verbal and nonverbal behaviors by another individual that were purposefully intended to hurt and control you, not tease or kid you"), physical neglect (i.e., "not having your basic life needs met"), and witnessing violence (i.e., "the first-hand observation of violence that did not directly involve you"). Response options were "yes" or "no." An overall measure of exposure to different types of trauma was developed by summing the number of different forms indicated by the respondent for a possible score that ranged from 0 to 5.
Borderline Personality Symptomatology. Borderline personality symptomatology was measured with the borderline personality scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rieder, 1987), an 18-item inventory which screens for borderline personality according to the criteria listed in DSM-III-R. Scores range from 0 to 8 and scores of 5 or higher are suggestive of BPD (i.e., the measure is designed as a dichotomous one, but in this study was used as a continuous variable to assess the degree of borderline personality psychopathology).
Depression. Current depression was measured with the depression subscale of the Symptoms Checklist-90-Revised (SCL-90-R; Derogatis, 1992), which consists of 13 symptoms of depression. Respondents were asked to indicate the extent to which each symptom was experienced during the previous 14 days using a five-point scale ranging from 0 (not at all) to 4 (extremely). The score is the mean rating across items. To minimize overlap among measures used in the study, we excluded two items (i.e., feeling low in energy or slowed down, feeling everything is an effort) which were similar to items in the somatic preoccupation scale, and one item (i.e., worrying too much about things) which was similar to items in the worry scale. The internal consistency coefficient (alpha) for the resulting 10-item depression scale was .92.
Worry Scale. Due to our inability to locate an established scale, a 12-item inventory was developed for use in the current study as a measure of self-reported tendency to worry (see Appendix). These were written as face-valid statements referring to the propensity toward worry, rumination, and uncertainty. Respondents indicated how self-descriptive each statement was using a four-point scale (1 = Not at all like me, 2 = A little like me, 3 = Somewhat like me, 4 = A lot like me).
Somatic Preoccupation. Somatic preoccupation was measured using the Bradford Somatic Inventory (Mumford et al., 1991), a 46-item, yes/no questionnaire. Developed from a cross-cultural perspective, items consist of those somatic symptoms reported most frequently by anxious and depressed patients. Two items relating to male respondents ("Have you had difficulty getting a full erection?" and "Have you felt that you have been passing semen in your urine?") were deleted due to concerns about their applicability in a mixedgender, U.S. internal medicine setting, resulting in a total of 44 items. Scores were computed based on the total number of symptoms endorsed.
With regard to our data analysis strategy, we first examined the psychometric properties of the Worry Scale as it was initially developed for this study. A principal components analysis of the 12 items comprising the Worry Scale resulted in a single component explaining 54.7% of the variance. All individual item loadings were .58 or greater. That a single component was underlying the 12 items was further reflected in the fact that the corrected itemtotal correlations ranged from .51 to .81, and the internal consistency coefficient (alpha) was .92. Accordingly, the Worry Scale appears to be measuring a single clinical phenomenon in a consistent fashion. A total worry score was computed by summing responses across the 12 items.
Simple Correlations Among Study Variables
Correlations among study variables are presented in Table 1. Note that, with only one exception, all correlation coefficients among variables are statistically significant and several are relatively substantial (most greater than .40). Therefore, at the univariate level, somatic preoccupation is related to childhood trauma, borderline personality symptomatology, worry, and depression, and all of them are generally related to one another.
In an effort to determine if there are unique relationships among variables, we undertook a path analysis. The advantage of a path analysis is that one can determine both direct and indirect effects of each variable after placement into an a priori model. The path analytic model results from a series of planned multiple regression analyses in which the influence of particular variables on the dependent variable (in this case, somatic preoccupation) are determined while statistically controlling for the effects of other, related variables. In this way, a "direct effect" is a relationship between a variable and somatic preoccupation after statistically controlling for the effects of the other variables in the model, and an "indirect effect" is a relationship between a variable and somatic preoccupation through an intermediate variable.
In our model, we developed a path beginning with childhood abuse and progressing to borderline personality symptomatology, to affective instability (current depression and worry), and ultimately to somatic preoccupation. The path coefficients (standardized regression coefficients) are reported in Figure 1, along with a diagrammatic representation of our model.
Specifically, we undertook four separate regression analyses. First, we examined the relationship between childhood trauma and borderline personality symptomatology. Second, we examined the relationships between depression and the precursor variables of childhood trauma, borderline personality symptomatology, and worry. Third, we examined the relationship between worry and borderline personality symptomatology. Finally, we examined the relationships between somatic preoccupation and the precursor variables of childhood trauma, borderline personality symptomatology, depression and worry. Note that childhood trauma exhibits both direct (i.e., independent) effects on somatic preoccupation as well as an indirect effect through depression. Childhood trauma also exhibits an indirect effect on somatic preoccupation through borderline personality symptomatology which, in turn, exhibits an indirect effect on somatic preoccupation through depression. Note that borderline personality symptomatology did not exhibit a direct effect on somatic preoccupation in the absence of depression. Last, worry exhibits an indirect effect on somatic preoccupation through depression. To summarize, childhood trauma appears to independently put one at risk for somatic preoccupation. In addition, depression appears to be the primary pathway through which borderline personality symptomatology and worry predispose one to somatic preoccupation.
These data indicate that the variables of childhood trauma, borderline personality symptomatology, acute depression, and somatic preoccupation are all at least moderately related when placed into a sequential model. Among previous studies examining the association between two variables (e.g., sexual abuse and somatic preoccupation, depression and somatic preoccupation), the clinician may develop the impression that there are distinct subgroups of somatically preoccupied patients (i.e., those with childhood trauma, those with depression). By examining multiple precursor variables within the same population, an inter-relationship of variables emerges (i.e., these data suggest that several psychiatric variables are simultaneously associated with somatic preoccupation).
While these findings are not likely to be applicable to all somatically preoccupied patients, the sequential linkage of multiple variables and somatic preoccupation may explain, in part, why some patients are very difficult to treat (i.e., comorbidity, trauma substrate). Recommended treatment is often psychosocial in nature including frequent visits and emotional support, as well as intervention with antidepressant and antianxiety medications (Righter & Sansone, 1999). Reasonable resolution of symptoms can be difficult to achieve and some symptoms may remain recalcitrant to intervention. These treatment impressions probably reflect that a subgroup of patients has a very complex amalgamation of psychiatric phenomena.
One critically important facet of this study is the association of somatic preoccupation with childhood trauma. From a psychiatric perspective, clinical experience indicates that trauma syndromes are difficult to treat, whether early developmental in nature or manifesting as PTSD from trauma in adulthood. Treatment is often multidimensional (i.e., psychotherapy, psychotropic medication) and responses may be limited in many cases. The psychiatric experience with trauma syndromes may be paralleling difficult-to-treat cases of somatic preoccupation in the primary care setting.
The explicit relationship between childhood trauma and somatic preoccupation in adulthood remains unknown. Research indicates that early sexual abuse and physical abuse demonstrate significant positive correlations with dissociation and somatization (Badura et al., 1997; Farley & Keaney, 1997); result in increases in hospitalizations and surgeries in adulthood (Salmon & Calderbank, 1996); and relate to fibromyalgia among some individuals (Walker et al., 1997). For victims of childhood abuse, somatic preoccupation may allow the avoidance of feelings and particular intolerable issues while enabling validation of self through physical suffering (Morse, Suchman, & Frankel, 1997). Likewise, pain may function as an obscuring response, allowing the somatically preoccupied patient to avoid the stimulation of even more painful traumatic memories (Walker et al., 1995).
There are several potential limitations with the current investigation. First, all data were based on self-report including the recollection of trauma. Trauma recollection can be compromised by dissociation, age at the time of the trauma, recall bias, and even the interpretation of abusive experiences (e.g., physical abuse misinterpreted as parental caring). Second, the measure for borderline personality, the Personality Diagnostic Questionnaire Revised [PDQ-R], has been criticized for being overinclusive (Patrick, Links, Van Reekum, & Mitton, 1995); therefore, we have characterized this measure as one of borderline personality symptomatology rather than the disorder per se. Third, our use of selected SCL-90 items (i.e., the depression subscale) rather than of the entire measure may have affected responses or results. In addition, the depression assessment was fairly brief in nature. Fourth, the Worry Scale was specifically developed for this study due to our inability to locate a measure of this type. Although the internal consistency of items was extremely high, specificity of the Worry Scale remains unknown. Fifth, the path analysis model entails a sequential ordering of variables based on theoretical expectations. However, all study variables were obtained at a single point in time, so that the actual sequence of variables remains unsubstantiated. Finally, these results reflect a patient population seen in a resident-staffed internal medicine clinic. Whether these findings can be generalized to other internal medicine or primary care populations (e.g., family practice) is unknown.
To our knowledge, this is the first investigation, based upon several study variables, to attempt to empirically unravel the multiple psychiatric threads of somatic preoccupation using a sequential model. Are these observations sustained among patients with bonafied DSM-IVsomatoform diagnoses? Are there variations in variables among the different somatoform disorders (e.g., pain disorder versus somatization disorder)? Are certain types of trauma or particular combinations of trauma more likely to precipitate somatic preoccupation in adulthood? Further research is needed to confirm and refine the proposed sequential model and to determine the extent to which the reported associations apply to various somatically preoccupied populations.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
Arnold, L. M., & Privitera, M. D. (1996). Psychopathology and trauma in epileptic and psychogenic seizure patients. Psychosomatics, 37, 438-443.
Badura, A. S., Reiter, R. C, Altmaier, E. M., Rhomberg, A., &Elas, D. (1997). Dissociation, somatization, substance abuse, and coping in women with chronic pelvic pain. Obstetrics & Gynecology, 90, 405-410.
Bass, C, & Murphy, M. (1995). Somatoform and personality disorders: Syndromal comorbidity and overlapping developmental pathways. Journal of Psychosomatic Research, 39, 403-427.
Brown, G. R., & Anderson, B. (1991). Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. American Journal of Psychiatry, 148, 55-61.
Bryer, J. B., Nelson, B. A., Miller, J. B., & Kroll, P. A. (1987). Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry, 144, 1426-1430.
Collect, B. J., Cordle, C. J., Stewart, C. R., & Jagger, C. (1998). A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners. British Journal of Obstetrics & Gyneacology, 105, 87-92.
Derogatis, L. R. (1992). SCL-90-R Administration, Scoring, and Procedures Manual-II. Towson, MD: Clinical Psychometric Research.
Farley, M., & Keaney, J. C. (1997). Physical symptoms, somatization, and dissociation in women survivors of childhood sexual assault. Women & Health, 25, 33-45.
Fossati, A., Madeddu, F, & Maffei, C. (1999). Borderline personality disorder and childhood sexual abuse: A meta-analytic study. Journal of Personality Disorders, 13, 268-280.
Goldman, S. J., D'Angelo, E. J., DeMaso, D. R., & Mezzacappa, E. (1992). Physical and sexual abuse histories among children with borderline personality disorder. American Journal of Psychiatry, 149, 1723-1726.
Herman, J. L., Perry J. C, & van der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146, 490-495.
Hudziak, J. J., Boffeli, T. J., Kriesman, J. J., Battaglia, M. M., Stranger, C., & Guze, S. B. (1996). Clinical study of the relation of borderline personality disorder to Briquet's Syndrome (Hysteria), Somatization Disorder, Antisocial Personality Disorder, and substance abuse disorders. American Journal of Psychiatry, 153, 1598-1606.
Hyler, S. E., & Rieder, R. O. (1987). Personality Diagnostic Questionnaire-Revised (PDQR). New York: New York State Psychiatric Institute.
Kellner, R. (1991). The significance of somatization. Homeostasis in Health & Disease, 33, 2-6.
Kolb, J. E., & Gunderson, J. G. (1980). Diagnosing borderline patients with a semistructured interview. Archives of General Psychiatry, 37, 37-41.
Lipowski, Z. J. (1990). Somatization and depression. Psychosomatics, 31, 13-21.
McCauley, J., Kern, K. E., Kolodner, K., Dill, L., Schroeder, A. R, DeChant, H. K., Ryden, J., Derogatis, L., & Bass, E. B. (1997). Clinical characteristics of women with a history of childhood abuse. Journal of the American Medical Association, 277,1362-1368.
Morse, D. S., Suchman, A. L., & Frankel, R. M. (1997). The meaning of symptoms in 10 women with somatization disorder and a history of childhood abuse. Archives of Family Medicine, 6, 468-476.
Mumford, D. B., Bavington, J. T, Bhatnagar, K. S., Hussain, Y, Mirza, S., & Naraghi, M. M. (1991). The Bradford Somatic Inventory. A multi-ethnic inventory of somatic symptoms reported by anxious and depressed patients in Britain and the Indo-Pakistan subcontinent. British Journal of Psychiatry, 158, 379-386.
Ogata, S. N., Silk, K. R., Goodrich, S., Lohr, N. E., Westen, D., & Hill, E. M. (1990). Childhood sexual and physical abuse in adult patients with borderline personality. American Journal of Psychiatry, 147, 1008-1013.
Paris, J., Zweig-Frank, H., & Guzder, J. (1994). Psychological risk factors for borderline personality in female patients. Comprehensive Psychiatry, 35, 301-305.
Patrick, J., Links, P., Van Reekum, R., & Mitton, M. J. E. (1995). Using the PDQ-R BPD scale as a brief screening measure in the differential diagnosis of personality disorder. Journal of Personality Disorders, 9, 266-274.
Polusny, M. A., & Follette, V. M. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Applied & Preventive Psychology, 4, 143-166.
Righter, E. L., & Sansone, R. A. (1999). The somatically preoccupied patient. American Family Physician, 59, 3113-3120.
Salmon, P., & Calderbank, S. (1996). The relationship of childhood physical and sexual abuse to adult illness behavior. Journal of Psychosomatic Research, 40, 329-336.
Simon, G., Gater, R., Kisely, S., & Piccinelli, M. (1996). Somatic symptoms of distress: An international primary care study. Psychosomatic Medicine, 58, 481-488.
Spinhoven, P., & van der Does, A. J. (1997). Somatization and somatosensory amplification in psychiatric outpatients: An explorative study. Comprehensive Psychiatry, 38, 93-97.
Van der Kolk, B. A., Hosteller, A., Herron, N., & Fisler, R. E. (1994). Trauma and the development of borderline personality disorder. Psychiatric Clinics of North America, 17, 715-730.
Walker, E. A., Katon, W. J., Hansom, J., Harrop-Griffiths, J., Holm, L., Jones, M. L., Hickok, L. R., & Russo, J. (1995). Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics, 36, 531-540.
Walker, E. A., Keegan, D., Gardner, G., Sullivan, M, Bernstein, D., & Katon, W. J. (1997). Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect. Psychosomatic Medicine, 59, 572-577.
Weaver, T. L., & Clum, G. A. (1993). Early family environments and traumatic experiences associated with borderline personality disorder. Journal of Consulting and Clinical Psychology, 61, 1068-1075.
Zanarini, M. C., & Frankenburg, F. R. (1997). Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 11, 93-104.
Randy A. Sansone
Wright State University School of Medicine
Michael W. Wiederman
Lori A. Sansone
Kettering Medical Center Physicians
Offprints. Requests for offprints should be directed to Randy A. Sansone, MD, Sycamore Primary Care Center, 2115 Leiter Road, Miamisburg, OH, 45342.
1. I worry about things that would not bother most other people.
2. I am bothered by uncertainty.
3. I get very nervous about certain things even though I know nothing bad is going to happen.
4. I tend to over-think things.
5. Once I start thinking about something, it is hard for me to let it go, or stop.
6. I find it hard to fall asleep because I keep thinking about things.
7. I tend to be a worry wart.
8. When faced with a decision, I get stuck thinking about it.
9. I spend a lot of time worrying.
10. Once I start worrying about something, it's hard to calm or reassure me.
11. When I have a problem, I tend to worry a lot about it.
12.1 often expect the worst to happen.…