Somatoform Disorders

Abstract

Patients present multiple somatic symptoms and demand for a medical extermination despite negative organic findings (dysfunctional illness behaviour). The doctor–patient relationship is often difficult. Basic interventions are: Take the physical complaints seriously, understand the patients’ helplessness, disappointment and anger and explore the subjective symptom believes. A 3-stage-model for interventions including a stepped-care approach is described.

FormalPara Case Study

Since childhood, Mrs. D. has regularly suffered from lower abdominal pain, sometimes associated with frequent bowel movements. She has not seen a doctor for the complaints for a long time. She has become accustomed to the on and off pain. For several weeks, the symptoms do not disappear completely. The pain has also worsened; it is so bad at times that she cannot fall asleep at night. She wakes up at night and has to go urgently to the toilet again and again, and this tenesmus is the worst for her. If it comes, she must immediately go to the toilet because she is afraid she cannot hold her stool, and the pressure is also very painful. Since she works by the hour as an assistant in a clothing store, she is very embarrassed. She always thinks of new excuses to tell to clients and colleagues, however, she herself no longer thinks of those excuses as being credible.(continued)

Definition

Internationally, the terms ‘Medically Unexplained Symptoms’ (MUS), ‘functional somatic syndromes’ and the diagnostic category ‘somatoform disorders’ of classification systems DSM and ICD are currently being used. MUS and ‘functional somatic syndromes’ are broader terms and do not carry a risk of stigmatisation of the patient . Especially in primary care settings in Western countries, the term ‘medically unexplained symptoms’ has gained popularity in recent years to describe the bodily complaints of patients when the aetiology is unclear.

The following terms may be distinguished:

• a. Medically unexplained symptoms (MUS): general term, very broad

• b. Functional syndromes: disturbance of bodily function rather than structure

• c. Somatization: a psychological problem or emotional disorder is expressed somatically

• d. Somatoform disorders: Diagnostic category in the psychiatric classification of Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD)

According to ICD 10, a somatoform disorder is characterized by the following features:

• Repeated presentation of somatic symptoms

• Stubborn and persistent demand for medical examination despite negative organic findings (dysfunctional illness behaviour)

• Emotional problems denied, although there is close relationship with psychosocial life events or conflicts (somatic fixation)

• Disappointing doctor–patient relationship (interpersonal disorder)

Relevance

About 20 % of patients who consult the family doctor have physical complaints with no adequate organic finding. The treatment of patients with symptoms without medical diagnosis is difficult. The patients explain their symptoms through a previously unrecognized physical illness, and initially, do not accept psychosomatic explanations. Because of the ensuing, often poorly developed motivation for psychotherapy, these patients are treated more frequently in general hospitals and medical practices of different disciplines than by a specialist in outpatient or inpatient psychotherapy. Extended time on disability and high costs due to the extensive use of inadequate medical diagnostics in outpatient and inpatient care when symptoms persist, demonstrate the importance of somatization phenomena in health care .

Theory

Symptoms

Somatoform symptoms may affect any organ system. The most frequent manifestations are shown in Table 11.1.

Table 11.1 Manifestations of somatoform symptoms

Most of the complaints listed in Table 11.1 are ascribed to certain diagnoses. It is thus suggested that the disease is physical. Accordingly, therapeutic success with medication, operation and other primarily somatic-oriented therapeutic procedures is low. Table 11.2 presents an overview of the diagnoses found in a wide variety of specialties, and in which somatization is usually present.

Table 11.2 Diagnosis in various specialties

Diagnostic Categories

Somatoform Disorders (ICD-10: F 45)

The following subclassification has proven helpful in practice :

• Undifferentiated somatoform disorder (ICD-10: F 45.1): Multiple somatoform symptoms for at least 6 months.

• Somatoform autonomic dysfunction of the vegetatively supplied organ systems like the heart, gastrointestinal tract, respiration and urogenital system (ICD-10: F 45.3) (Table 11.1).

• Persistent somatoform pain disorders (ICD-10: F 45.4)

• Hypochondriacal disorders (ICD-10: F 45.2): The patient is excessively occupied over long periods with the possibility of suffering from one or more serious, progressive physical diseases. Everyday physical sensations are misinterpreted as threatening and stressful.

• In body dysmorphic disorders, the body is interpreted as being deformed. This is usually accompanied by a desire for cosmetic surgery.

Dissociative Disorders (ICD-10: F 44)

Dissociation means literally ‘splitting of the consciousness’. Examples are feelings of alienation, like depersonalization and derealization, loss of memory and escapism, semiconsciousness and non-epileptic convulsions.

These phenomena occur frequently in connection with severe emotional traumata, especially after experiences of violence and sexual abuse. No verbal working out of the event is possible. The traumatic experience is split off and finds expression as fear, states of vegetative tension and in the symptoms described under ‘posttraumatic stress disorders’.

Differential Diagnosis

Somatoform symptoms may also be part of an anxiety disorder or depression. Feelings of anxiety or depressive symptoms are not experienced consciously, but are expressed at the physical level. We also speak here of affect equivalent. See Fig. 11.1 for the overlapping of somatization, anxiety and depression.

Fig. 11.1

Overlapping of somatization, anxiety and depression

Outlook on DSM-V and ICD-11

The concept of ‘medically unexplained systems’ fosters the dualism of mind and body. The patient’s symptoms are seen either as organic (‘medically explained’) or ‘medically unexplained’ which may be taken to imply a psychosocial cause. This is still enshrined in the classification of diseases (ICD, DSM) despite the fact that we know that illness is determined by a mixture of biological, psychological and social factors. To overcome this issue of dualism, there is a need to describe relevant factors on all three dimensions (biological, psychological and social) contributing to the distress and suffering of patients with often multiple somatic symptoms.

The next editions of the diagnostic classification systems DSM-V and ICD-11 are in preparation. Intense discussions are currently being held about the future of the category of ‘somatoform disorders’. Critics of the current classification point out that, among other issues, the division into organ-medical and psychological conditions is questionable, the current description of the definition is not culturally sensitive, a number of disorders within the category of somatoform disorders are unreliable, and that the diagnostic criteria of somatization disorder are too narrow .

A result of this criticism is a push for a positive definition of somatoform disorders, including illness perception and illness attribution, illness behaviour, health-related anxiety, emotional distress, disability, quality of life, doctor–patient interaction and health care utilisation. The current proposals by the DSM-V working group suggest that these disorders might be subsumed in the future under the diagnostic label of ‘Complex Somatic Symptom Disorders’ (CSSD). The following preliminary criteria have been specified for CSSD:

To meet criteria for CSSD, criteria A, B and C must be met:

• 1. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.

• 2. Excessive thoughts, feelings and behaviours related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:

  • a. High level of health-related anxiety.

  • b. Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.

  • c. Excessive time and energy devoted to these symptoms or health concerns.

• 3. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).

Frequency and Course

The 12-month prevalence of somatoform disorders in the European adult population is 6.3 % (Wittchen et al. 2011). After anxiety and affective disorders, they are ranked third in terms of frequency of occurrence. Somatoform disorder is diagnosed much more frequently in women than in men.

An American study (Kroenke and Mangelsdorff 1989) examined the proportion of physical diseases for the ten most frequent complaints over a 3-year period. An organic cause was identified in only 16 % of 1,000 patients. Functional somatic symptoms/somatization was probable in a large number of the remaining patients (Fig. 11.2).

Fig. 11.2

Physical complaints in a 3-year-course

Onset

Every person reacts to emotional stress with physical symptoms, such as sweating, insomnia, palpitations, diarrhoea etc. MUS-patients either do not perceive the emotional stress, or there is inhibition in expressing emotions. The attention is focused instead on the accompanying physical symptoms, which undergo negative assessment and potentiation and are no longer associated with the eliciting feelings. Complaining of the physical pain replaces the expression of unpleasant feelings.

In a vicious circle, the physical symptoms increase the fear, which in turn results in greater physical symptoms (Fig. 11.3).

Fig. 11.3

Vicious circle

The following psychosocial factors promote somatization :

• Traumatization in childhood

• Negative bonding experience

• Model learning from parental models, who experience similar complaints

• Tendency to emotional and physical overtaxing

• Low self-esteem, easily insulted and hurt

• Strengthening of the role of illness with increased attention and support of the environment

• Relief from social or family demands and responsibilities as a result of the complaints

Practice

Recognition

Signs of somatoform disorders may be :

• The symptoms do not follow anatomic or physiological patterns

• The report of the symptoms is diffuse

• Complaints are accepted without emotion on the one hand, described in dramatic images and inadequate effects on the other

• The patient appears lamenting, demanding clinging

• There are other complaints which cannot be adequately explained organically

• Frequent change of doctor (doctor shopping)

• Current stress, such as at work, or in the family.

Practical Tip: ‘Pain History’

• What relieves the pain?

• What aggravates the pain?

• What does a typical day with pain look like?

• Is there a change in pain level during the day?

• When did the pain first occur?

• What kind of experiences with respect to pain are there in the family and personal history?

Basic Therapeutic Attitude

The objective of treatment in psychosomatic primary care is to establish an empathic and trusting doctor–patient relationship, in which the patient feels that he is being taken seriously in his complaints and his view of the illness. After an organic disease has been ruled out, other explanation models can then be discussed and, if necessary, the patient motivated to accept further psychotherapeutic treatment. Treatment goal is relief of complaints, not cure. Regular appointments, e.g. every 14 days, is recommended.

The following belong to a basic therapeutic attitude:

• Take the physical complaints seriously

• Understand the patient’s helplessness, disappointment and anger

• Even if the doctor does not believe there is an organic cause of disease, the patient should at least undergo brief physical examination

• No precipitous coupling of reported or presumed emotional stress with the physical complaints

• Patience, calmness and knowledge of the limitations of therapeutic possibilities

Basic Interventions

The 3-Stage Model

For treatment in primary care, the 3-stage model has proven helpful.

Stage 1: Feeling Understood

• Take a full history of the symptoms

• Explore emotional problems

• Explore social and family factors

• Explore symptom beliefs

• Past similar problems and treatment

• Brief, focused physical examination

Following a detailed description of all physical ailments, the doctor elicits the disease and treatment expectations of the patient.

Case Study (continued)

Doctor: What do you think is causing your abdominal pain?Patient: I know it sounds silly, but my mother had uterine cancer and it started with such abdominal pain. I often think that no one has recognized my cancer yet.Doctor: Do you worry a lot about it?Patient: Yes.Doctor: If you agree, I’ll examine you physically now.(continued)

Short, targeted physical examinations, coupled with empathy for the physical symptoms convey to the patient a serious attitude towards his/her physical experience.

The diagnosis should be done as a parallel or simultaneous diagnosis of somatic and psychosocial factors. Even during their first visit, patients should be asked about their mental wellbeing.

Careful physical examination should be repeated at regular intervals, especially with persistent somatoform complaints. In this way, changes in symptoms can be detected in time, it will give the patient a feeling of security and of being taken seriously, and ideally complex instrumental tests are avoided. In case of emerging symptoms, somatic as well as psychosocial diagnosis should be adjusted or extended.

Stage 2: Establish the Agenda Through Negotiation

Objectives of the second treatment step:

• Acknowledge distress or symptoms

• What does the patient want?

• Feedback the results of the examinations

Case Study (continued)

Doctor: The laboratory tests, ultrasound and computer tomography have not shown evidence of an organic disease. I would like to examine your abdomen…. Your abdomen is sensitive in the middle area, but I don’t find anything else remarkable. But I can imagine that you suffer a lot from your complaints.(continued)

Stage 3: Making the Link

Objectives of this third treatment step:

• Reframe the complaints: link symptoms with stress or lifestyle

  • Three-level explanation for anxiety (Fig. 11.4)

    Fig. 11.4

    

    The relationship between anxiety, physiological reaction and somatic symptoms

• Agreement

  • Acknowledge bodily distress

  • Treatment of depression, anxiety

  • Self-management strategies

  • Watchful waiting

  • Psychotherapy

Development of an alternative model of disease by explaining psychophysiological relationships, such as between fear and physical symptoms. The following phrases can be used here:

‘In frightened people, the body excretes more adrenalin. That’s why their hearts beat faster in situations of fear’.

‘If people are worried, or are depressed, the intestines can contract and that causes abdominal pain’.

Everyday body-related expressions are especially helpful, such as ‘when the heart skips a beat, makes you sick to your stomach, gets under one’s skin’.

In this phase, we also recommend the use of a symptom diary (Table 11.3) in which the perception of complaints and their misassessment, such as the fear of having a serious illness, are captured. These cognitive and emotional processing mechanisms can be addressed and discussed during doctor visits, i.e. be placed in new contexts.

Table 11.3 Symptom diary for a better understanding of pain

Practical Tip: ‘Symptom Diary’

‘There are a lot of different causes of stomach ache. You see what has already been examined. We’ll find the problem together. I would like to get a complete picture again of the complaints you have. Please keep a pain diary until your next appointment’.

The record of thoughts and feelings when abdominal pain and tenesmus appeared are discussed and re-evaluated with the patient .

The links between the appearance of physical symptoms and stressful life situations are explained and the patient is motivated for psychotherapeutic treatment.

Case Study (continued)

Doctor: You mentioned last time that you were having problems at work?Patient: Yes, some jobs are to be made redundant, and I’m really worried. Sometimes I even cry.Doctor: I see you’re tense and sad at the moment. Physical tension can cause muscle cramps and cause such pain as you are now having.Patient: You think that’s related to my abdominal pain?Doctor: I think your worries may be affecting your stomach.Patient: You believe that the muscles in my abdomen are cramping and causing my stomach ache? But my being sad, does that cause pain, too?Doctor: Yes, of course. Can you relax, for example when you are in bed?Patient: Oh, no.Doctor: I think that’s a result of the worries you have.Patient: Hmh—could be. But what can I do about it?Doctor: How do you feel when you talk about it?Patient: It does me good to show you what I’m feeling and know you’ll understand. I try to be strong, but I really have no idea what’s going to happen next.Doctor: I think psychotherapeutic interviews could help you to deal better with your anxieties and worries about your job and help to you relax.Patient: What do ‘psychotherapeutic interviews’ mean, exactly?

The occurring stressful emotions are linked to the physical discomfort. Encouragement to verbalize feelings, to express criticism and to assert of one’s own position has a relieving and symptom-reducing effect.

Other Treatment Measures

Physical or athletic activation, e.g. aerobic endurance training, active form of physical therapy should be well prepared and accompanied by sustained motivation. The intensity should to be gradually increased, alternating with rest periods.

Drugs, e.g. for the regulation of cardiac dysfunction, symptomatic drug therapy for irritable bowel syndrome and for pain relief should be used only after a critical risk-benefit assessment and only for a limited time.

Psychopharmaceutical Treatment

In more severe, pain-dominant somatoform disorders with and without accompanying depressive symptoms, antidepressants of different classes are moderately effective. For non-pain dominant somatoform complaints additional temporary antidepressants should be given, only in clinically relevant mental comorbidity of anxiety or depression .

Pitfalls

The doctor believes he has recognized the psychosomatic relationships and would like to share his/her knowledge with the patient. However, the patient does not accept the interpretation of the doctor. On the contrary, because of the interpretation of the physician, the patient closes himself/herself even more and increases the presentation of physical complaints. For the treatment, it is important to recognize that one’s own understanding is not relevant. The decisive factor is the willingness of the patient to be open to alternative explanations.

The doctor wants to proceed too quickly with the motivation for psychotherapy. The treatment of medical complaints without sufficient medical finding is a very gentle process and requires a lot of sensitivity.

Cooperation

The referral to an outpatient or inpatient psychotherapeutic treatment takes best place as part of a stepped-care model (Table 11.4).

Table 11.4 The stepped-care model in primary and secondary care. (Adapted from Henningsen et al. 2007)

For deciding which treatment step is appropriate for a patient with unexplained physical symptoms, the algorithm shown in Fig. 11.5 may be used to assist (Kroenke 2003).

Fig. 11.5

Algorithm of the management of patients with somatic complaints

Cognitive-behavioural treatment methods are effective in terms of improving the physical comfort, the quality of life and in reducing health care costs. In chronic fatigue syndrome, fibromyalgia and in not organically related heart problems improvements were found on the symptom level. A psychodynamic treatment approach has been shown to be effective in patients with functional upper and lower abdominal complaints (irritable bowel syndrome).

Cultural Aspects

Nonspecific, functional and somatoform symptoms occur in all cultures, but differ with respect to the complaint type, the explanatory models, the attribution of importance and expression. In addition, there are ‘culture specific syndromes’, which exist only within a defined culture. Ethnic minorities and refugees, due to increased psychosocial stress due to emigration, including communication problems, report probably more often about nonspecific functional and somatoform symptoms.

The somatic presentation is part of patient’s illness behaviour. It does not necessarily mean that the patient is unable to present emotional problems or does not know how to make psychological complaints. It simply indicates that the patient presents somatic symptoms from numerous reasons, including that he is following a culturally moulded pattern of problem presentation as pointed out by Kirmayer and Young (1998). The presentation of somatic symptoms has multiple indications: It can be seen as an index of a disorder, an indication of a psychopathology, a symbolic condensation of intrapsychic conflicts, a culturally coded expression of distress, a medium for expressing social discontent, and a mechanism through which patients attempt to reposition themselves within their local worlds. That means the nature of somatic presentation needs to be understood and grasped dynamically rather than merely given the label of somatization for somatoform disorders.

The concept and category of ‘somatoform disorders’ is a product of the contemporary professional orientation, that dichotomatizes the body and mind and categorizes disorders simply by the nature of symptomatic manifestation.

There are no systematic cross-cultural differences in the overall incidence of somatoform symptoms (Gureje et al. 1997; Kirmayer and Young 1998). The irritable bowel syndrome seems to be more common in Western cultures than in non-Western (Chang et al. 2006), as well as multiple chemical sensitivity or the sensitivity to amalgam (Hausteiner et al. 2005).

In Latin American countries and also in other countries, the concept regarding the causes of different diseases varies considerable between traditional medicine and formal medicine. Although there is a direct and mutual influence among both systems in terms of the diagnosis and treatment processes of any disease, popular treatments are not limited to professionally defined diseases but deal to a large extend with psychosocial and emotional conditions. What health professionals describe as specific diseases are not necessarily aligned with diseases defined by the popular knowledge. The decision of the patient of seeing a doctor or a healer depends on factors including perception of the cause of the disease, severity of the disease and accessibility to health services.

Somatic Symptoms as Cultural Idioms of Distress (Iran)

The idiom of ‘heart distress’ among Iranians can be understood as a culturally prescribed way of talking about a host of personal and social concerns primarily related to loss and grief (Laurence and Young 1998). Many Iranian people complain of tensions, distress and worries by words related to ‘heart’. The word ‘del’ is used by people pointing to both heart and abdomen. Both parts of the body are the origin of many discomforts. ‘Del dard’ refers to abdominal pain and discomfort, though ‘dard e del’ means telling some secrets or ventilation due to tensions or sad events. So, many psychosomatic complaints are related to ‘del’. Although the patient’s narrative of his or her illness may include a significant subtext, it links his or her physical distress to social predicaments, moral sentiments and otherwise unexpressed emotions. Throughout the Middle-East, reference to the heart is commonly understood not just as potential signs of illness but as natural metaphors for a range of emotions.

Somatic complaints are the most common and important causes of visits in different clinics (Ahmadzadeh and Masodzadeh 1997). Variety and number of somatic complaints of patients who visited psychiatric clinics are more than of patients who are referred to medical and dermatologic clinics. In several studies, the main complaints in depressive patients were somatic complaints. The most common complaints in psychiatric clinics are headaches, muscular and joint pains, generalized fatigue, palpitation and GI complaints. Somatic presentation is the most common presentation of depressive disorders in the Iranian patient population. Somatic presentations are more common in depressed women, in the geriatric population and in low-socioeconomic groups. Fear of stigmatization and acceptance of somatic complaints instead of emotional expression and verbalization of affective suffering are the principle cause of this phenomenon.

Certainly, most of the psychiatric patients who visited a psychiatrist for the first time, had visited general practitioners and other specialists due to somatic complaints which causes unnecessary workups and spending resources, and finally a delay in diagnosis and mismanagement in this group.

Neurasthenia (China)

The term neurasthenia was introduced in the USA by New York neurologist George M. Beard in 1869 (Beard 1869). It was very popular at the time and included about 30 symptoms. The diagnostic concept spread around the world, and it was referred to as shenjing shuairuo in China and shinkei shuijaku in Japan. Shenjing shuairuo includes somatic, cognitive and emotional symptoms. Patients whose clinical picture included sleep disorders, dizziness, headaches, concentration disorders, rapid exhaustion and many other similar symptoms very often received this diagnosis (Kleinman 1982; Yan 1991). Despite its origin in Western psychiatry, shenjing shuairuo has become a popular concept in Chinese folk medicine.

Symptoms such as weakness and exhaustion are important in traditional Chinese medicine, and they are related to a lack of ‘qi’ or hypofunctioning of ‘kidney’, imbalance between ‘yin and yang’, hyperfunctioning of ‘liver’, or imbalance between the function of ‘kidney’ and ‘heart’. Its origin was regarded as organic, but the treatment consists of psychological and social therapies such as traditional Chinese medicinal herbs, acupuncture, qi gong and shadow-boxing. In addition, drug therapy, physical therapy and group psychotherapy were used after a philosophical and medical consideration of patients. The concept of shenjing shuairuo additionally has the advantage not to be stigmatising.

In 2001, the concept of somatoform disorders was introduced into the Chinese Classification of Mental Disorders (CCMD-III). At the same time, hierarchical rules were established permitting the diagnosis of shenjing shuairuo only after exclusion of depressive disorders and anxiety disorders. Neurasthenia received code 43.5 in the CCMD-III and therefore ranked behind other forms of somatoform disorders. As a result, shenjing shuairuo is now rarely diagnosed by Chinese psychiatrists. However, in neurological and general hospitals outside the major urban centres, the diagnosis is still used.

Dissociative Disorder and Pain Disorder in Vietnam

Symptoms of dissociative disorder are functional paralysis and loss of voice. Recently, trance and possession disorder has been seen in Vietnam. In this state, the dead person invades patients and helps their alive relatives to find out the place of his/her grave.

Somatized pain disorder is often seen. Pain usually occurs in chest, head, joint etc. Stomach, intestinal and muscular disturbances are detected as their symptoms. The relation between pain and other somatic disorders as cardiologic disorders, endocrinologic disorders etc., is unexplained. Patients with these disorders often go to somatic departments first. They usually go to see psychiatrist later. According to some studies, somatized disorder was recognized after 2–2.5 years of onset.

Psychopharmacology is of common use in psychiatry. Using psychotherapy among these patients is still limited because lacking of experts and clinical psychologists in Vietnam.

Body Dismorphic Disorder (Latin America)

In tropical countries, such as the Latin American continent, where more exposure of the body happens, research evidenced a high prevalence of Body Dismophic Disorder (dismorphia), which concerns with body shape and skin perfection. It ranges from 1 to 2 % in the general population and it gets as high as 16 % in dermatological and cosmetic surgery patients. The majority of the patients experience some degree of impairment in social or occupational functioning, and obsessive thoughts may lead to repetitive behaviours and to attempted suicide in the more severe cases. Research findings show that most individuals have poor insight and cannot acknowledge that what they indeed need is psychiatric treatment because their physical problem is indeed minimal or inexistent. The most frequent dermatological concerns are dyschromias, acne, the shape of the body and ageing. Research has also evidenced that a reasonable number of patients had already performed clinical or surgical treatments with poor results. Moreover, some comorbidities were encountered such as: major depressive disorders and obsessive compulsive disorders.

Other examples of culture-specific syndromes that can broadly be considered somatoform disorders include:

Brain-fag (Nigeria)

‘Brain-fag’, first described in 1960 in southern Nigeria (Prince 1960): cognitive impairments, visual and other sensory disturbances and various physical complaints, mainly burning pain in the head and neck area. Brain fag is subjectively attributed to mental stress (Tseng 2006).

Dhat (India, Nepal, Pakistan, Bangladesh and Sri Lanka)

Various body symptoms such as fatigue, weakness, loss of appetite, sexual dysfunction, caused apparently by nocturnal loss of semen in the urine (Tseng 2006). (see also chapter anxiety disorder).

Arctic Hysteria (Greenland)

‘Pibloktoq’ or ‘Arctic Hysteria’, first described in 1913 in Northwest Greenland: Sudden consciousness disorders up to the loss of consciousness associated with behavioural problems such as tearing clothes off the body, swearing, tossing objects, mostly occurring in women in the Arctic winter, most likely under extreme physical and psychological stress, but was also attributed to hyperglycaemia or hypervitaminosis A (Tseng 2006).

Pain Syndrome (East Africa)

‘Hapa na Hap’ Syndrome means pains here and here. A description of somatisation symptoms such as headaches, tiredness, constipation, or other unspecific symptoms, commonly by health workers in Kenya (Jenkins et al. 2010).