Somatizations

Nearly all the patients presented one or more complaints for which no organic cause was demonstrable and which proved to be art expression of the psychological problem. The very rare exception was the patient who came explicitly for an interpersonal or situational problem with his anxiety relatively well-circumscribed by the problem. Both sexes of all age groups illustrated the readiness with which somatization is utilized in emotional conflict. Thus the majority of patients had at one time or another visited a doctor to obtain relief for these symptoms. Some, with simpler symptoms, had tried self-medication. Many had been subjected to various physical examinations and laboratory procedures. Several had been hospitalized in the process of determining the illness and it was not unusual for the first interview to occur while the patient was still in the hospital. A few had consulted “herbolarios” (quack doctors who, interestingly enough often prescribed medications similar to the doctor’s.)

Aside from consulting doctors and taking pills, patients tried other measures to obtain relief. Local herbs, particular foods, body massage, prayers and novenas were some of these. Distracting activities, such as keeping busy, visiting friends, “going our,” playing with the children or limiting one’s physical activities were tried. Usually the symptoms created much concern in the parents, if the patient was single, or in the spouse, if married. There were only a few cases wherein the patient chose to keep the distress a secret from the spouse or parents, going to great lengths to avoid discovery. As may be expected, the suffering grew worse and eventually become known.

As a rule, therefore, the somatic symptoms afforded generous secondary gains for the patients in terms of attention from loved ones and doctors as well as release from responsibility. Once in a while, a patient would be accused by the family of putting on an act or imagining things, but this tended to be the exception. Somatic symptoms were readily given credence and were therefore greatly effective in eliciting concern from others. This may also be one reason why somatization seems to have a high incidence. It effectively calls attention, whereas other kinds of symptoms do not.

Headache was the most common somatic symptom in both male and female groups. Descriptions varied: splitting, throbbing, pounding, head felt “tight,”“heavy,”“enlarging,”“being pulled.” It was not usually localized over any particular area although “heaviness on the forehead” and “pressure right on top” and “tight nape” were mentioned many times. Women tended to describe their distress in more dramatic terms, e.g. “like firecrackers going off in my head,” while the men often expressed the fear of brain cancer or a stroke. There were no discernible patterns in time of appearance. There were nine patients, six of whom were women, whose description of their headache suggested strongly a migrainous type. Aside from the one-sided splitting headache, at times so severe as to be more of a pain than an ache, there were other symptoms of nausea, vomiting, and pain in the eyes. Two of these six women always closeted themselves in their darkened bedroom whenever the attack came. The degree of incapacitation varied greatly. As a rule, it caused enough distress but did not by itself restrain the patient from pursuing his usual activities.
In the search for the cause of the headache, the eyes, nose, teeth, and sinuses were often exhaustively examined. In addition, many of the patients had availed themselves of neurological and electroencephalographic aids. Several women demonstrated a regularity in the relationship of headache to the pre-menstrual period.
It seems impossible to categorize any typical emotional conflict found in the patient with severe headache. In some, it was clearly an equivalent of rage. In others, it expressed a frustration with the self and one’s inability to use one’s mental powers to master a problem. In others, the headache came with despair. Like most of the other somatic symptoms, it had different meanings for different patients. It did not seem to serve a directly symbolic value in the way that conversion symptoms did.

Dizziness, which followed closely the complaint of headache in frequency, seldom came as an exclusive symptom. Quite often, it came together with headache. Among the men, it was mentioned as a prodromal symptom to “blacking out” or to impaired equilibrium in walking or standing. Although many women mentioned dizziness as one of their symptoms, only two suffered from it to such a degree that previous doctors had entertained the possibility of Meniere’s disease. The rest of the women experienced it as part of a generalized diffused clinical disturbance. Thus, as part of an anxiety attack, it came with palpitations, choking sensations, and the like. Or as part of the prodromata to a fainting spell, dizziness would be complained of in addition to chest oppression or body weakness.

The complaint of “black-out” or “as if I will black out” was heard only from men. There was no actual loss of consciousness and the descriptions conveyed an impression of momentary confusion with blurring of thought. The patient never fell nor hurt himself. The usual reaction was one of alarm at experiencing something strange happening to one’s thought processes. One patient while watching a movie suddenly had a momentary feeling “as if something snapped inside my head.” He lost track of what was going on around him.

Fainting spells and “convulsions” were confined to women. Here, an actual loss of consciousness was claimed, although not much reliance could be placed on this. In no instance did a patient sustain injury from falling. These episodes usually occurred in the home, although a few happened in schools or in church. The “convulsions” as described and as seen by the author followed no specific patterns, and ranged from thrashing about to uncontrolled movements of one body part. Jerky head-shaking was seen in two young girls.

Gastric upsets and vague abdominal pains, chest or “heart” pains came next in frequency to headache and dizziness. Over a fourth of the patients in each group, male and female, had a symptom referable to either the digestive tract or to cardiac function. The fear of peptic ulcer or stomach cancer was heard more often from male patients. There were six cases previously diagnosed by X-ray as duodenal ulcer; of these, five were men. The three cases of repetitive belching or burping were men. However, vomiting as a conversion mechanism was twice more frequent in women than in men. Diarrhea as an occasional concomitant of emotional distress was cited more frequently by males, but the four diagnosed cases of ulcerative colitis were equally divided between the two sexes. Patients from both groups described the gastric discomfort as “feelings of fullness,” gassiness” (kabag). The quality of the pain was variable, in some patients coming as a dull ache and in others, usually women, as colic-like.

Anorexia was not impressive as a solitary symptom, except in a few very depressed patients. However, when it occurred with nausea and vomiting, as it did with at least five women, the combined result was disastrous. In general, families seemed particularly alert to their acting habits. Weight loss, if present, was usually the first thing mentioned to the doctor.

Going hungry was an obsessional fear in four women. It was not related to a lack of food intake but to another fear, namely, that delayed meals or allowing hunger pangs to go unappeased would result in graver illness or graver attacks of “nerves.” Thus, these women were never without candy or biscuits (one of them carried around a bottle of soft drink) in their handbags.

With gastric upsets was a good deal of fussiness about food and precautions about eating. Eating meals on time, refraining from icy-cold drinks, avoiding coffee or certain soft drinks, were given undue emphasis.

Chest symptoms centered around the heart and the feat of a heart attack. In some cases, notably women, subjective dyspnea was complained of. No cases of hyperventilation were encountered such as were seen at the psychiatry clinic of the Philippine General Hospital. Women tended to be more vague about their chest symptoms, describing it as a feeling of oppression or constriction. Men directly associated it with fear of a heart attack.

A heart  attack was generally regarded as a fatal illness and the fear of one was attended with considerable apprehension and anguish by the patient and members of his family. It was not unusual to have the spouse or one member of the family always in attendance, and the internist available on call at any time, to give reassurance. Chest pains were described in different ways: “pricking, like a needle”; “heaviness over the left chest”; “feels like my left chest is being tightly squeezed”; painful pounding” (palpitations). Some of the ways of describing the pains reflected the hyperanxious state of the patient: “My heart feels like it might just snap”; “My heart is filling up with water, I might drown.” A popular Tagalog expression described the heart as swollen or inflamed (izamamaga).

Other symptoms which tended to be confined to one sex rather than the other were the following: In men, poor balance when standing or walking, eye pains, low back and groin pains, and urinary disturbances (such as difficulty in starting the flow and pain during micturition); in women, numb feelings over various parts of the body, tremors, tingling sensations, hot and cold sensations not related to menopause, feeling feverish or chilly, unusual sensations over tongue, choking sensations, foreign body sensation in the throat, body weakness, fatigue, and urinary frequency. The lips, tongue, and throat seemed to be particularly vulnerable organs in women; while the eyes, legs, and lower trunk seemed to be the counterpart of these in men.

These symptoms differed also in quality of onset and impact on the two groups of patients. Those presented by men were acute and dramatic in onset. The patient responded with great anxiety and alarm to what he perceived is an imminent catastrophic event. If he cannot use his legs, he must be getting paralyzed. His eye pains could be the beginning of blindness. The low back and groin pains and difficulty in starting micturition could be the start of impotence. Those presented by women were reacted to with less alarm. Many of the women seemed to have had some experience with them in the past so the symptoms were not altogether strange or unfamiliar. Even choking sensations and numbness of the lips which evoke fright did not create the near-panic reaction which male patient3 had with their symptoms. Several women presented a syndrome of symptoms led by fatigue and body weakness, followed by a medley of many other ill-defined aches and pains like gastric upsets, dysmenorrhea, dizziness and headache. They fit rather well into the old category of “neurasthenia.”
Some patients described the body disturbance in bizarre sounding phrases. This may mean nothing more than too free a translation from a vernacular expression to English. For, example, a patient who said cold particles were traveling in her muscles had her counterpart in the patient who says in Tagalog, “Napasukan ng lamig ang mga laman ko”; or the one who says his arms and legs have become paralyzed may be translating from a vernacular term “pasma,” for a condition wherein the hands or feet feel stiff, cramped, numb or tired, and the veins prominent. This condition is believed to be a result of overwork, hunger, or exposure to draft or cold. The Tagalog equivalents were suggested by statements of patients seen at the psychiatry OPD of the Philippine General Hospital, who generally belonged to lower economic groups and often came from rural areas. The Tagalog expressions likewise had little scientific basis and might even sound weird to one who has not lived long enough among Filipinos.

Apart from these liberties with translation, there was a definite tendency in many patients to give rather unusual descriptions. The patient may state the somatic disturbance ‘as if he were a passive victim of an active process, exemplified in the expression: “Inatake ako. . . ,“ meaning, literally, “I was attacked by. . .“ probably a more graphic version of the English “I was seized with Many expressions imparted the patient’s apprehension over parts of his body getting out of control. In extreme cases, it was as if he were literally coming apart. Many of these patients chose a more dramatic phraseology for effect at the expense of accuracy. Unless the statement is clearly in simile form, it is difficult to tell whether the patient is employing theatrics or describing an actual psychological experience. Some statements may cause a psychiatrist’s ear to perk up in suspicion of more malignant psychological processes lurking undercover. Particularly to Western psychiatrists, they may earn the labels of somatic delusions or autistic thinking. In the patients in this study, they revealed nothing more than what appeared to be idiosyncratic tendencies in Filipinos to choose certain verbal symbols in conceptualizing body image, body function and body disturbance.

Examples of these are:

“My flesh is falling off.”

“The back of my head has solidified.”

“My head is being pulled up and the rest of my body, too.”

“The organs inside my body are falling.”

“Something inside my abdomen is breaking.”

“My throat is closing up.”

“I feel warm sensations from the back to the front of my tongue.”

“My eyes seem to be falling out.”

“Lines go back and forth in front of my eyes.”

“The skin on the sides of my nose is decaying.”

“I wear dark glasses when I go our, otherwise I feel like falling or stumbling.”

“There is a foul smell from my scalp, on the left side.”“A vein on my left temple feels so tight it’s going to break.”“My head feels compressed and flattened on one side.” My veins are like rope—hard and tight.”

“A cold feeling stabbed me right in the middle of my back
and slowly went up the back of my neck. Now my neck feels tight.”

Four adolescent patients, three girls and one boy, all under twenty years, described one unusual symptom. Each felt that there was something “awful” or “shameful” on his or her face causing extreme self-consciousness and, when seen by others, painful embarrassment or humiliation. What this shameful or awful thing was could not be defined or elucidated, although associations to it suggest sexual thoughts and impulses. The boy eventually localized “it in his eyes. For a long time he felt that whenever people looked straight into his eyes, they saw something which made them turn away in disgust. The discovery by other people can happen anywhere—on the bus, in church, in class, and other places. One of the young girls arrived for her session, upset and excited, because she felt that from the way the taxi driver looked at her that morning, he had detected “it.” The complaint is reminiscent of delusions sometimes expressed by psychotics about the face.