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PTSD Questions & Answers
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Joyce Boaz & Dr. Frank Ochberg, M.D.

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Other Conditions: Somatization Disorder or Briquet's Syndrome.

Q: Dear Frank:

Occasionally, one of our GFW survivors describes overwhelming physical distress, including fatigue, headache, allergy, muscle and joint pain, menstrual problems and even convulsions. How common is this? Is it caused by childhood abuse?

A: Dear Joyce, This is a very important issue, and one that can be difficult for a therapist and a client to discuss. Yes, indeed, close to 2% of women in America are plagued with real medical conditions that are often painful and of grave concern. I am not talking about imaginary symptoms or malingering. These are genuine maladies, with evidence on X-rays, MRIs, blood tests and meticulous physical examination. The cause may be hard to ascertain, but the expression of illness is obvious to the patient, her doctor and others who are concerned. When just a single organ is involved, or a single physiological system is involved - say the lung and the pulmonary system, or the heart and the circulatory system - a specialist is brought in and a "work-up" is undertaken. If a cause is found, a treatment plan is launched. But when a cause cannot be found, symptoms are "palliated" with various remedies and the patient may or may not feel better.

With the group of women who fall into this 2% of multi-system sufferers, one agony leads to another. After a while, many doctors, clinics and hospitals are involved. Pain, stress and dread are felt and communicated. Doctors get frustrated, because they cannot succeed in helping. Some doctors are very patient, and they are sources of comfort and clear feedback, although they cannot relieve every source of suffering. Some doctors use derisive terms and antagonize the patient. At some point a referral is made to a psychiatrist. On several occasions, I have been that psychiatrist.

Of course, I want to know all about the patient. In my experience, the patient has always been female. In reviewing the scientific literature, it is common for this pattern to affect women and extremely rare for it to affect men. I'm not sure why. I get called because the woman grew up with trauma - inescapable trauma, from an early age. It could be father-daughter incest. It could be sadistic punishment for minor mistakes. It could be cowering in fear as a bully beat a mother or a sibling, even though my patient was spared. Her virginity might have been spared. Her body may have been spared. But she was a captive in her own toxic family and her future was poisoned.

There are several different theories for why this early abuse may result in later multi-system medical problems. One is that the brain turns fear and dread into physical pain. Another is that a victim becomes super-sensitive in order to escape harm, but cannot escape and is left with hyper-vigilance that will not turn off. Being hyper-vigilant is emotionally and physically stressful. Body chemistry leads to alterations in the immune system and one is prone to infection, allergy and "auto-immune" diseases like lupus. Again, this theory does not suggest imagined illness. It defines a cause of real illness in many organs and organ systems. Look up "psychoneuroimmunology" or PNI to read more. When I was a medical student at Johns Hopkins in the early 1960s, we called this field Psychosomatic Medicine.

But the word, psychosomatic, came to imply that the conditions were feigned or imagined rather than real. We knew they were real. We wanted a name for the science of diagnosing and treating this reality that would not stigmatize our patients, hence, PNI. There's another theory. Women who run this gauntlet from abused child to multi-organ medical patient become, understandably, filled with fear and negative thought. They lose their ability to calm themselves and they are filled with pessimism. That makes their condition worse. And it makes treating them a difficult, often unrewarding activity for caregivers.

Additionally, the search for a medical or surgical cure is demanding, expensive, time consuming and frustrating. Nevertheless, every medical condition must be adequately researched. Pain in the chest could be coronary artery disease. We can't stop looking for causes, just because someone fits a pattern of "somatization."

And many of the symptoms of this syndrome are treatable. A person who gets migraine headaches, skin rashes, painful menses and fatigue can benefit from interventions that treat each one of those symptoms.

But what can a woman do who is an adult survivor of childhood abuse and who falls into this "2% pattern"? First, she can make the connection in her own mind and admit to herself that her real medical issues are made worse by her negative emotion. Some people know they have negative emotion, but they refuse to work on that emotion. They are fearful and accusatory - for good reason - but they cannot relate to FDR's powerful proclamation, "the only thing we have to fear is fear itself." (Of course, there are many things to fear, other than fear itself, but too much fear is a terrible burden).

You can reduce fear through many non-medicinal means. CBT and DBT are tools in the therapists' tool kit. They only work with patients who admit they have excessive emotionality and who gather the gumption to work on their own fear response rather than blame others.

Second, she can limit her doctor shopping and find one primary care physician who has the patience to stay the course, to appreciate her history, and to use specialists as needed - but to also use mature mental health professionals to help mitigate negative emotion.

Third, she can work with a trauma expert when she is healthy enough to explore the frightening and humiliating "ghosts" from the past. The problem I find when I am that trauma expert is that medical emergencies and exaggerated fear of well-meaning caregivers interfere with work on post-traumatic injury. Or the "ghosts" are still so frightening that they are avoided rather than confronted.

My answer to these obstacles is patience. It can take a long time. But patience and tolerance are necessary ingredients. The syndrome that affects 2% of women -- that is 3 million Americans - was first described in 1859 by a Frenchman named Briquet. It should not be a cause for self-denigration to accept the term, Briquet's syndrome. It helps define a reality. It helps the caregiver as well as the survivor contend with painful truth. Briquet's syndrome and Somatization Disorder are the same thing. I appreciate this opportunity to write to our GFW community and to encourage all of us to recognize, with respect, those who suffer with this long-term burden.

Here is a good, clear article on the relationship between childhood abuse and later somatiform disorder - http://www.academia.edu/1582109/Child_Abuse_and_Somatoform_Disorders

The term Somatiform Disorder refers to several related conditions
Somatization Disorder or Briquet's syndrome
Conversion
Body Dysmorphic Disorder

In sum, you can develop Briquet's without being abused as child, but there is a strong correlation. There are many millions of abused kids. A relatively small percentage go on to develop Briquet's. Eating disorders and other psychiatric syndromes are associated with childhood abuse.

Frank

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