|Year : 2019 | Volume
| Issue : 2 | Page : 108-113
Stressful life events and quality of life in patients with somatoform disorders
Ramesh Ammati1, Anil Kakunje2, Ravichandra Karkal3, Ganesh Kini3, Jeyaram Srinivasan3, Dilshana Nafisa3
1 Department of Psychiatry, Institute of Mental Health, Osmania Medical College, Hyderabad, Telangana, India
2 Department of Psychiatry, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
3 Department of Psychiatry, Yenepoya University, Mangalore, Karnataka, India
|Date of Submission||12-Apr-2018|
|Date of Decision||30-Jul-2018|
|Date of Acceptance||16-Feb-2019|
|Date of Web Publication||26-Jun-2019|
Dr. Anil Kakunje
Department of Psychiatry, Yenepoya Medical College, Yenepoya University, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Stressful life events are associated with somatoform disorders. Somatoform disorders can influence the quality of life (QOL). These factors are culture-specific and less studied in the Indian population. Objective: The objective of this study was to evaluate the stressful life events and QOL in patients with somatoform disorders. Materials and Methods: This cross-sectional observational study was done by examining the life events and QOL of 112 consecutive patients who were diagnosed with somatoform disorders. Mini Neuropsychiatric Interview Plus, Presumptive Stressful Life Events Scale (PSLES), and WHO Quality of Life-Bref scales were administered. Results: The study sample had undifferentiated somatoform disorder (32.1%), persistent somatoform pain disorder (26.7%), and somatization disorder (25.9%). The common stressful life events experienced by somatoform disorder patients were financial issues (27.7%), marital conflicts (20.5%), family conflicts (18.7%), and illness in family members (16%). Males reported predominantly financial and job-related stressors, whereas females reported stress in family and interpersonal domain. The mean stress score using PSLES among the participants was 114.9, and the score of mean life events experienced by the participants was 2.03. QOL scores in domains such as physical, psychological, social relationship, and environment were 44.3, 41.4, 46.6, and 47.7, respectively. These were low when compared to population norms. There was a significant positive correlation between the duration of the somatoform disorder and the stress scores and a negative correlation which was not significant between the duration of illness and QOL. Conclusions: There is a difference between stressors experienced between the two genders, the knowledge of which would help in tailoring individual needs in management. There is significant impairment in the QOL in people with somatoform disorder.
Keywords: Life event, quality of life, somatoform disorder, stress
|How to cite this article:|
Ammati R, Kakunje A, Karkal R, Kini G, Srinivasan J, Nafisa D. Stressful life events and quality of life in patients with somatoform disorders. Indian J Soc Psychiatry 2019;35:108-13
|How to cite this URL:|
Ammati R, Kakunje A, Karkal R, Kini G, Srinivasan J, Nafisa D. Stressful life events and quality of life in patients with somatoform disorders. Indian J Soc Psychiatry [serial online] 2019 [cited 2022 Jul 2];35:108-13. Available from: https://www.indjsp.org/text.asp?2019/35/2/108/261476
| Introduction|| |
Repeated and varying presentation of physical symptoms without any obvious physical cause or disease is the characteristic of somatoform disorders. The term somatoform is derived from the Greek word, “soma” for body. Somatization was initially found to have a relation with the psychoanalytical concept of conversion where the person expresses psychological conflict as somatic or physical symptoms. The term “somatization” was first used by Stekl to denote “the expression of emotional distress as bodily symptoms.” Lipowski regarded somatization as a process and a disorder as well and defined somatization as a “somatic idiom of psychosocial distress.” Somatization is normally considered as an outcome of mind and body's reaction to stressful life events. Exposure to chronic and recurrent stress may cause certain changes in the stress biochemical axes, thereby producing the somatic symptoms.,
Somatization is a clinical problem which can lead to socio-occupational dysfunction and increased health-care utilization. The World Health Organization estimated the prevalence of unexplained symptoms among primary care patients across 15 different countries as 22%, but there was a wide variation across centers. A systematic review of the prevalence of somatization and medically unexplained symptoms found that the point prevalence for the diagnosis of at least one somatoform disorder according to the Diagnostic and Statistical Manual (DSM)-III R or later and International Classification of Diseases (ICD)-10 was 26.2% and 34.8%, respectively.
Stressful events were defined as occurrences that were likely to bring about readjustment-requiring changes in people's usual activities. Stressful life events contribute significantly to the development of major psychiatric disorders. Similarly, life events play a significant part in the causation of neurotic illness. Neuroticism, psychoticism and dissociative experiences, and abnormal illness behaviors are significantly related to the stress perceived by the patient.
Childhood sexual abuse is one of the main stressful life events in adult women with somatization disorder and conversion disorder., Life events related to family, finance, and marital issues were high in patients with functional somatic symptoms. There is a strong association between stressful life events and the process of somatization.,,, The study of Chandrashekhar et al. in India observed loss of loved ones, large loans, son/daughter getting married or leaving home, and conflict with in-laws to be the common life events in persons with somatoform disorder.
Quality of Life (QOL) has become increasingly a health-care topic. Improvement in QOL ratings causes substantial decrease in expenditure over time, especially in mental illness. Studies showed that there is impairment in the QOL in patients with somatoform disorder.,,, There is limited research related to impairments in QOL in patients with somatoform disorder from India. This study aimed to look into the type of stressful life events experienced by patients with somatoform disorder and QOL among them in the Indian context.
| Materials and Methods|| |
Study design and setting
This was a cross-sectional observational study with serial sampling conducted in the outpatient and inpatient services of the department of psychiatry of a tertiary care teaching hospital from January 2016 to December 2016.
Patients aged between 18 and 60 years satisfying the ICD-10 criteria of somatoform disorder (ICD: F45) except hypochondriacal disorder (F 45.3) were taken as the study population. Patients with other psychiatric comorbidities except nicotine dependence, definite organic cause, and intellectual disability, as judged by clinical evidence, were excluded from the study. Consecutive patients who met the inclusion criteria and provided written informed consent were included in the study. Ethical clearance was obtained from the Institutional Ethics Committee.
Demographic details were collected using a specially designed pro forma which included age, sex, occupation, educational status, religion, marital status, and income details.
Diagnosis was made using the Mini International Neuropsychiatric Interview version 5.0.0 which is a short structured diagnostic interview for DSM-IV and ICD-10 diagnosis. It also helped to rule out psychiatric comorbidity, and the time taken for administration was around 15 min.
Presumptive Stressful Life Events Scale was used to look into stressful life events. This scale was developed by Singh and Kaur and Kaur (1984) using stressful life events relevant to Indian culture and standardized in the same population. This scale consists of 51 life events commonly experienced by normal Indian adult population. Hundred was the highest stress score and, zero was considered as no perceived stress. Both quantitative and qualitative analyses of life events are possible on this scale. It is also possible to measure stress over different time scales.
QOL was measured using WHOQOL-Bref scale. This scale was developed by WHO quality of life group. This is an abbreviated version of WHO QOL-100. The WHO QOL Bref contains 26 items: two items from the overall QOL and general health and one item from each of the remaining 24 facets included in the WHO QOL-100. This scale assesses the QOL in four domains namely, physical health, psychological, social relationships, and environment with a time frame of 2 weeks. The scale has been shown to have good discriminant validity, sound content validity, and good test–retest reliability at several international WHOQOL centers.,,
All the data were entered in MS Excel and analyzed using Statistical Package for the Social Sciences version 22 (IBM Corporation, New York, USA).
| Results|| |
A total of 112 patients were included in the study. Mean age in years of the sample was 36.6 (±9.63). Among the study population, a majority of patients were between 30 and 40 years of age (39.2%), followed by 40 and 50 years (25.9%) and 20 and 30 years (24.1%). In the study sample, 63 patients were females (56.2%) and 49 patients were males (43.7%). Ninety-eight patients were married (87%), 8 were widow/widower (7%), 3 were unmarried (3%), and 3 were divorced (3%). Religion-wise distribution among the study population was 80 Muslims (71.4%), 30 Hindus (26.7%), and 2 Christians (1.78%). Majority of the study population had primary school education (64.2%). Nearly 52% of the study population belonged to middle class and 35% of the population belonged to low socioeconomic status as illustrated in [Table 1].
Among 112 patients, 36 patients had diagnosis of undifferentiated somatoform disorder (32%), 30 patients had diagnosis of persistent somatoform pain disorder (26.7%), 29 patients had diagnosis of somatization disorder (26%), 8 patients had somatoform autonomic dysfunction (7.1%), 5 patients had other somatoform disorder (4.5%), and 4 patients had unspecified somatoform disorder (3.5%). In this study, 45% of the patients had the duration of illness between 5 and 10 years and 14% had duration more than 10 years.
Stressful life events
[Table 2] shows the mean stress score of the study population to be 114.9, and the score of the mean life events experienced by the population sample to be 2.03.
[Table 3] provides the details of the stressful life events.
When the stressful life events were compared between males and females, male patients commonly had life events related to financial problems and illness in family members, whereas females reported life events related to marital conflicts and interpersonal relationship issues as shown in [Table 4].
Quality of life
QOL scores were compared with population norms given by the WHO as shown in [Figure 1].
|Figure 1: Quality of life scores in comparison with the normal population|
Click here to view
| Discussion|| |
Discussion on demographic details
Demographic variables of the study revealed that around 40% of the individuals were between 30 and 40 years of age, with mean age of the population being 36.6 ± 9.63 years. Studies have shown that age of onset for somatoform was mostly around 20 years and would present to psychiatric services late as it has chronic and fluctuating course. In our study, 56% of the participants were women. Literature also reports higher prevalence of somatoform disorder among women. Women are more likely to mislabel a given sensation to be unpleasant and as a symptom., Nearly 87% of the study population were married and were living with family, which is typical of Indian population. In a study by Nakao et al., it was found that married persons report somatic symptoms less likely than singles, but in contrast to that another study by Aragona et al. found that married people are more prone to report somatic symptoms than singles. In the Indian scenario, even in patients with severe mental illness, there is a good marital outcome without any gender differences. Michael Nunley mentioned his observations about the role and extent of family involvement in Indian culture when compared to the West in taking care of mentally ill patients. The high number of Muslims in the study sample is due to the higher Muslim population in the catchment area of hospital compared to the national average. The mean duration of illness for the sample was 4.64 years. Nearly 80% of the study sample had illness duration more than 2 years, 45% of the population had illness duration between 5 and 10 years, and 14% of the population had duration more than 10 years. In a study by Garala et al. in India about somatization, the mean duration of illness was 6.8 years, and a majority of the population had long course of illness more than 2 years, and it was also found that somatization disorders were common at younger age, in females, and in those from low socioeconomical background. Our study also showed similar findings.
Stressful life events
In our study, females experienced more stressful life events. When stressful life events were compared between males and females, the difference is stark. Males experienced more life events related to financial issues and females experienced more life events related to relationship issues either in family or marital life. In comparison with studies from other countries, Morrison and Walker et al. mentioned that there is higher somatic symptom reporting in women with childhood sexual abuse., A study by Poikolainen et al. in Finland found that, in female adolescents, there is a positive association between somatic symptoms and life events such as serious illness in family and familial conflicts between parents and relationship issues. Indian studies on functional somatic symptoms have reported life events related to financial and relationship issues.,
Spearman's correlation was done to explore the relationship between duration of illness and total stress scores. There was a highly significant positive correlation between the two (0.692).
A large number of clinical research has mentioned that somatoform disorders generally have a temporal relationship with stressful events. Many theories explained the role of stressful events in the causation of somatization due to dysfunction of stress response system. Lazarus mentioned that not only stressful life events determine the negative outcome, but the individual appraisal and perception of the event also play an important role.
Quality of life
When compared to the population norms, the quality of life score in the study population was markedly low in all domains such as physical, psychological, social relationships, and environmental.
These findings were similar to the study done by Kuriakose and Gupta in Indian population, in which it was found that QOL was significantly impaired in somatoform patients, and it was found to be associated with certain demographic factors such as sex, educational status, and duration of illness. In our study, the associations between QOL scores and certain demographic factors were not statistically significant. Spearman's correlation test was done to explore the relationship between duration of illness and QOL. There was a negative correlation which was not statistically significant (−0.02). Though somatoform disorder is not considered a severe mental illness, somatoform disorders such as schizophrenia and bipolar disorder significantly impair the QOL.,
Knowing the common stressful events in the culture would help in clinical interview and understanding the patient's condition and background better which would in turn help in better psychosocial management. The average duration of illness in the sample was 4.64 years and few above 10 years also, which is a matter of concern. The QOL was not significantly affected by the duration of illness in this study, which means people in the early phase of the illness are also having significant impairments in their QOL.
The strengths of study are that the sample includes only somatoform disorders after excluding other psychiatric comorbidities, fairly good sample size, and assessments were done by using culture-specific and standard scales. Limitations in the study are that personality factors were not assessed, there is no comparative normal population, and the study was conducted at a tertiary hospital, and hence the results cannot be generalized to the population. Future studies can be planned with larger sample size, in comparison with the normal population. Stressful events could vary in different cultures, and hence need studies from different regions/populations.
| Conclusions|| |
Stressful life events are high and play a significant role in somatoform disorders. Common stressful life events in Indian population are related to financial issues in males and interpersonal/family conflicts in females. There are differences in stressors experienced by the two genders and its knowledge would help in interviewing and managing somatoform disorders. QOL was impaired in patients with somatoform disorders in all domains such as physical, psychological, social relationship, and environmental. The impairment is not correlated to the duration of illness and almost similar to other psychiatric disorders.
The finding of the study helps to understand the common stressors faced by our population and also to understand the importance of QOL in somatoform patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Marin C, Carron R. The origin of the concept of somatization. Psychosomatics 2002;43:249-50.
Lipowski ZJ. Somatization: The concept and its clinical application. Am J Psychiatry 1988;145:1358-68.
Agoha BC, Ilobi U. Stressful life events and somatic complaints in a Nigerian adult sample. Niger J Psychol Res 2010;6:10-7.
Russell J, Shipston M, editors. Neuroendocrinology of Stress. Chichester, UK: John Wiley and Sons, Ltd.; 2015.
Kumar MS, Kamal D, Sumitra G, Ranjan B, Nitu M, Hamid A. Role of stress and coping strategy in maintenance of symptoms in somatoform disorders. Int J Multidiscip Res Dev 2014;2:447-58.
Kallivayalil RA, Punnoose VP. Understanding and managing somatoform disorders: Making sense of non-sense. Indian J Psychiatry 2010;52:S240-5.
] [Full text]
Fink P, Hansen MS, Oxhøj ML. The prevalence of somatoform disorders among internal medical inpatients. J Psychosom Res 2004;56:413-8.
Haller H, Cramer H, Lauche R, Dobos G. Somatoform disorders and medically unexplained symptoms in primary care. Dtsch Arztebl Int 2015;112:279-87.
Dohrenwend BP. Inventorying stressful life events as risk factors for psychopathology: Toward resolution of the problem of intracategory variability. Psychol Bull 2006;132:477-95.
Seedat S, Stein DJ, Jackson PB, Heeringa SG, Williams DR, Myer L, et al.
Life stress and mental disorders in the South African stress and health study. S Afr Med J 2009;99:375-82.
Cooper B, Sylph J. Life events and the onset of neurotic illness: An investigation in general practice. Psychol Med 1973;3:421-35.
Irpati AS, Avasthi A, Sharan P. Study of stress and vulnerability in patients with somatoform and dissociative disorders in a psychiatric clinic in North India. Psychiatry Clin Neurosci 2006;60:570-4.
Morrison J. Managing somatization disorder. Dis Mon 1990;36:537-91.
Roelofs K, Keijsers GP, Hoogduin KA, Näring GW, Moene FC. Childhood abuse in patients with conversion disorder. Am J Psychiatry 2002;159:1908-13.
Geetha PR, Sekhar K. Alexithymia in rural health care. NIMHANS J 1995;13:53-7.
Patel DV, Dutt J. A study of stressful life events and somatoform disorder. Int J Sci Res 2014;3:472-4.
Nizami A, Hayat M, Minhas FA, Najam N. Psycho-social stressors in patients with somatoform disorders. J Pak Psychiatr Soc 2005;2:20-3.
Nacak Y, Morawa E, Tuffner D, Erim Y. Insecure attachment style and cumulative traumatic life events in patients with somatoform pain disorder: A cross-sectional study. J Psychosom Res 2017;103:77-82.
Chandrashekhar CR, Reddy V, Isaac MK. Life events and somatoform disorders. Indian J Psychiatry 1997;39:166-72.
] [Full text]
Kuriakose A, Gupta S. Quality of life and health care utilization in patients having somatoform disorder. Int J Curr Res 2013;5:1838-42.
Duddu V, Husain N, Dickens C. Medically unexplained presentations and quality of life: A study of a predominantly South Asian primary care population in England. J Psychosom Res 2008;65:311-7.
Zonneveld LN, Sprangers MA, Kooiman CG, van 't Spijker A, Busschbach JJ. Patients with unexplained physical symptoms have poorer quality of life and higher costs than other patient groups: A cross-sectional study on burden. BMC Health Serv Res 2013;13:520.
Nickel R, Hardt J, Kappis B, Schwab R, Egle UT. Determinants of quality of life in patients with somatoform disorders with pain as main symptom – The case for differentiating subgroups. Z Psychosom Med Psychother 2010;56:3-22.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al.
The mini-international neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.
Singh G, Kaur D, Kaur H. Presumptive stressful life events scale (PSLES) – A new stressful life events scale for use in India. Indian J Psychiatry 1984;26:107-14.
] [Full text]
The World Health Organization quality of life assessment (WHOQOL): Development and general psychometric properties. Soc Sci Med 1998;46:1569-85.
Sartorius N. A WHO method for the assessment of health-related quality of life (WHOQOL). In: Quality of Life Assessment: Key Issues in the 1990s. Dordrecht: Springer; 1993. p. 201-7.
Skevington SM, Lotfy M, O'Connell KA; WHOQOL Group. The World Health Organization's WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res 2004;13:299-310.
Hawthorne G, Herman H, Murphy B. Interpreting the WHOQOL-BREF: Preliminary population norms and effect sizes. Soc Indic Res 2006;77:37-59.
Tomasson K, Kent D, Coryell W. Somatization and conversion disorders: Comorbidity and demographics at presentation. Acta Psychiatr Scand 1991;84:288-93.
Kroenke K, Spitzer RL. Gender differences in the reporting of physical and somatoform symptoms. Psychosom Med 1998;60:150-5.
Bener A, Ghuloum S, Burgut FT. Gender differences in prevalence of somatoform disorders in patients visiting primary care centers. J Prim Care Community Health 2010;1:37-42.
Barsky AJ, Peekna HM, Borus JF. Somatic symptom reporting in women and men. J Gen Intern Med 2001;16:266-75.
Nakao M, Fricchione G, Zuttermeister PC, Myers P, Barsky AJ, Benson H, et al.
Effects of gender and marital status on somatic symptoms of patients attending a mind/body medicine clinic. Behav Med 2001;26:159-68.
Aragona M, Monteduro MD, Colosimo F, Maisano B, Geraci S. Effect of gender and marital status on somatization symptoms of immigrants from various ethnic groups attending a primary care service. Ger J Psychiatry 2008;11:64-72.
Thara R, Srinivasan TN. Outcome of marriage in schizophrenia. Soc Psychiatry Psychiatr Epidemiol 1997;32:416-20.
Nunley M. The involvement of families in Indian psychiatry. Cult Med Psychiatry 1998;22:317-53.
Garala V, Brahmbhatt M, Shah H, Vankar G. Somatization and health seeking behavior. Int J Res Med Sci 2014;2:956.
Walker EA, Katon WJ, Hansom J, Harrop-Griffiths J, Holm L, Jones ML, et al.
Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658-64.
Poikolainen K, Kanerva R, Lönnqvist J. Life events and other risk factors for somatic symptoms in adolescence. Pediatrics 1995;96:59-63.
Murberg TA. The influence of optimistic expectations and negative life events on somatic symptoms among adolescents: A one-year prospective study. Psychology 2012;3:123-7.
Garner JM. Stress and Somatic Symptoms: Rumination and Negative Affect as Moderators. Clinical Psychology Dissertations 10; 2016.
Lazarus RS, Folkman S. Stress, Appraisal, and Coping. Vol. 11. New York: Springer; 1984. p. 445.
Michalak EE, Yatham LN, Lam RW. Quality of life in bipolar disorder: A review of the literature. Health Qual Life Outcomes 2005;3:72.
Solanki RK, Singh P, Midha A, Chugh K. Schizophrenia: Impact on quality of life. Indian J Psychiatry 2008;50:181-6.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4]