Somatization Disorder: Briquet’s Hysteria

Michael Trimble

INTRODUCTION

The term “hysteria” is as old as the earliest medical writings, and classic descriptions of symptoms we now refer to as conversion disorder are found in the texts of the Egyptians, Greeks, and Romans. However, it is also clear that there were early descriptions of polysymptomatic patients, with chronic somatic symptoms outlined. Edward Jorden (1569-1632), a physician of London and Bath, in his treatise, A Briefe Discourse of a Disease called the Suffocation of the Mother described the case of a charwoman, Elizabeth Jackson, who was accused of bewitching the 14-year-old Mary Glover. The latter had convulsions, episodes of loss of speech, periodic blindness, paralysis, and loss of sensation down the left side of the body. Also noted were aggressivity and personality changes. Jorden recognized not only the polymorphous nature of the symptoms, but also a link of such a profile to the female sex and the importance of perturbations of the mind as a cause of the disorder (1).

Sydenham (1624-1689), who considered hysteria to be one of the commonest medical conditions in his practice, also recognized the chronic nature of the disorder and noted the personality contributions, which included capriciousness, and labile moods and affections (2).

Robert Brudenell Carter (1828-1918) divided hysteria into two main forms: the simple and the complicated. The former manifests mainly as hysterical seizures, but the latter was a foreboding of the later Briquet’s form. It “generally involves much moral and intellectual, as well as physical derangement, and when it is fully established, the primary convulsion, the fons et origo mali is sometimes suffered to fall into abeyance … being arrested by the urgency of new maladies (3).” He was writing in the 19th century, which saw an explosion of interest in the condition of hysteria, particularly from the German and French physicians. It was in this context that Pierre Briquet embarked upon his writings.

BRIQUET AND HIS SYNDROME

Pierre Briquet (1796-1881) became chief physician to the Paris Charité, and he readily admitted that he undertook to study hysteria as a matter of duty, on account of the frequency of cases that he reluctantly had to examine.

His book Traité Clinique et Thérapeutique de L’Hystérie (4) reported on the results of personal examinations of nearly 450 patients, and is a 19th-century landmark in hysteria studies. It was to have a considerable influence on Charcot and his school, and then later on the development of today’s concept of somatization disorder. Briquet, in contrast to a number of other theorists, rejected uterine theories of causation of the condition, and clarified the presentation of hysteria in men. He outlined the multifarious symptoms, including the spasms, anesthesias, convulsions, paralyses, and contractures, which have become familiar in descriptions of patients diagnosed with hysteria over time.

Briquet referred to the length of time that the symptoms lasted. Of 418 patients, 179 had the condition for between 6 months and 4 years, 81 between 5 and 10 years, and of the rest, it lasted a longer time. Thus, in 59 patients the condition had continued more than 20 years, and in five patients for 55 years. These patients were polysymptomatic, and were clearly forerunners of the later-christened Briquet’s hysteria. Briquet incidentally opined that hysteria was a condition of that portion of the brain which received sensations and affective impressions, and he described hysteria as a nervousness of the encephalon.

The notion of chronic hysteria fell into some abeyance with the writings of Charcot and Janet, who became more interested in the underlying personality structure of patients who might be susceptible to suffering from hysteria and the precipitating mental events. Freud, too, was more concerned with the psychological traumas involved, although clearly he treated patients with multiple physical symptoms, many of which persisted for years, and included neuralgias and anesthesias of various kinds, contractures and paralyses, hysterical attacks and other kinds of seizures, anorexia, vomiting, and disturbances of vision. Freud commented, “the disproportion between the many years’ duration of the hysterical symptom and the single occurrence which provoked it is what we are accustomed invariably to find in traumatic neuroses (5).”

A renewed interest in Briquet’s hysteria, rechristened chronic hysteria, and evolving to the rather clumsy, inelegant term “somatization,” occurred in the mid-20th century (6). The term somatization was originally introduced to neuropsychiatry through the writings of the psychoanalyst Stekel (1868-1940), who used the term “somatizieren” to refer to neurotic patients who expressed their mental states symbolically as somatic symptoms (7). The term “somatization” made a limited appearance in America in the 1940s, but the concept seems to have been crystallized by three influential authors some 3 decades later. Lipowski (7) considered somatization to be, rather as the concept of conversion was becoming at that time, a disorder as well as a process. Kleinman (8) defined somatization as an expression of distress in the idiom of bodily complaints and medical help seeking, thus placing the concept firmly in a cultural setting. Then, in 1983, Ford wrote his book The Somatizing Disorders, which was subtitled Illness as a Way of Life. This was a landmark contribution to the field, and somatization was defined as follows: “… a process by which the body (the soma) is used for psychological purposes or for personal gain. Any one symptom or constellation of symptoms may concurrently serve more than one function, including issues related to intrapsychic conflicts, intrapersonal relationships, and social or environmental problems (9).”

Contemporary research into patients with somatization disorder evolved from the work of Cohen et al. at Harvard and Guze, at St Louis. Purtell et al. (10) described a group of patients, mainly women, who presented with a chronic disorder manifesting a wide variety of unexplained medical complaints. In this paper, they refer to the condition as hysteria, but use the soubriquet Briquet to name the syndrome.

CONTEMPORARY CLASSIFICATIONS

In the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II), there are hysterical neuroses—conversion type (300.13) and hysterical neuroses—dissociative type (300.14). In conversion disorder, the special senses of the voluntary nervous system are affected, while in the dissociative type, alterations to the state of consciousness are seen.

Further editions of the DSM retain a similar division. However, in DSM-III, the term “somatoform disorders” emerges with various subtypes including somatization disorder (300.81). The use of the subcategory somatization relates back to the studies of the St. Louis group and essentially incorporates their concept of Briquet’s hysteria. It was seen as separate from conversion disorder, but sadly, the eponym was seen as superfluous and was discarded.

However, the concept of Briquet’s hysteria is to be found both in DSM-IV and The International Classification of Diseases (ICD-10). Referred to as somatization disorder in DSM-IV (300.81), and the same in the ICD-10 (AF 45.0), it represents a chronic condition, and the patients by definition are polysymptomatic. This is seen in contrast to conversion disorder, with a much more restricted symptomatology, which tends to run a shorter course.

The original criteria for Briquet’s hysteria, as given by Perley and Guze (11), required the patient to have 25 out of 59 possibly medically unexplained symptoms, coming from nine out of ten possible symptom groups. However, over time, a fewer number of complaints have been included, such that in DSM-III, the requirements were 14 symptoms for women and 12 for men from a list of 37, and in DSM-III-R, 13 symptoms from a list of 35 were needed.

The full criteria given in DSM-IV are shown in Table 21.1. The requirements are a history of many physical complaints over a period of several years, but with rather specific numbers of complaints from four main areas, namely, pain symptoms, gastrointestinal and pseudoneurologic symptoms, and sexual complaints.

The diagnosis of somatization disorder comes under the overall category of somatoform disorders, and corresponds well with the original concept of Briquet’s hysteria.

The essential features are the development of medically unexplained symptoms, usually before the age of 30, for which the patient seeks medical advice and treatment, or which causes significant social and occupational impairment. Sometimes symptoms occur in association with some relevant somatic pathology, but in such settings, the complaint exceeds that which would normally be expected.

According to DSM-IV, patients often describe their complaints in “colorful, exaggerated terms,” they are often inconsistent historians, and their lives can be as chaotic as their medical history.

The ICD-10 refers to somatization disorder as describing a patient who presents “multiple recurrent, and frequently changing physical symptoms, which have usually been present for several years before the patient is referred to a psychiatrist. Many patients have a long and complicated history of contact with primary and specialist medical services, during which many negative investigations or fruitless operations may have been carried out (12).” Central features, in addition to longstanding multiple and variable physical symptoms which carry no physical explanation, are
a persistent refusal to accept the advice or reassurance of doctors that there is no physical explanation for the symptoms, and some degree of impairment of social and family functioning attributable to the behavior.

TABLE 21.1 SOMATIZATION DISORDER: DIAGNOSITIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH EDITION, CRITERIA

A.	A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.
B.	Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:
	(i)	four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
	(ii)	two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
	(iii)	one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
	(iv)	one pseudoneurologic symptom: a history of at least one symptom or deficit suggesting a neurologic condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)
C.	Either (i) or (ii):
	(i)	after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
	(ii)	when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings
D.	The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).