Understanding

Mental Health
2001 depression.org.uk
site design and implementation - Octopus Associates Ltd. www.oal.co.uk
SOMATISATION OF DEPRESSION
Prof. Simon Wessely
Lecture at the Royal Society of Medicine 29th October 1999
Information Center
page 1
Im going to talk about somatisation. It is customary to
start off with a defnition, which bores half the audience
to tears, followed by classifcation, which then removes
the other half as well, so Im not going to do that. The
reason Im not going to do that is because its really
not an area where psychiatry should pontifcate. As in
so much of psychiatry and depression as well, this is an
area in which psychiatrists make up classifcations for
patients that we rarely ever see. Patients are seen by
neurologists, physicians , cardiologists, GPs and so on
and its not really for us to say how they should be
classifed.
First of all, somatisation is about the experience of
physical symptoms, somatic meaning of the body, the
experience of physical distress as opposed to psycho-
logical distress, feeling miserable, weepy, tired and so on.
Its also a disorder, called somatisation disorder, which
Im not going to mention at all because psychiatrists
invented it. Thirdly, its a process. Im really going to stick
quite a lot with this idea of somatisation as process, a
way in which patients communicate with doctors, a way
in which people interact with the health service. A very
infuential defnition from David Goldberg talks about
the patient coming to see the doctor for help with
their physical symptoms, so they come to say because
Ive got chest pain as opposed to because Im feeling
weepy. The patient feels that these are due to physical
problems, their concern might be due to heart disease
as opposed to I might have depression. However, the
doctor in his wisdom feels that it is quite likely that
the problem is due to depression. Finally and the least
convincing of all, is that when you treat depression the
patient, gets better. Well well skirt over the last one,
because thats the weakest link in the chain as it doesnt
always happen.
First of all, question number one, is it true that depres-
sion is associated with physical symptoms Well, yes, it
is. There are over 60 studies on the subject and rather
than go through them, youll be pleased to know that
its quicker to state there is no study in existence, of
which Im aware, that does not a fnd strong association
between physical symptoms and depression. Depressed
patients have physical symptoms, period. Hence, indeed I
would say all depressed patients have physical symptoms
and it tends to be things like feeling tired, feeling weak,
having headaches and pains and so on which are top
of the list, time after time. If we look the other way
round, if we look at the symptoms in the community,
we fnd that many of those symptoms are in turn due
to depression as well. So, if we look at populations with
pain, unexplained fatigue and so on, we fnd that many,
but not all, are also due to depression.
Depression is always associated with physical symptoms,
physical symptoms are quite often, but not always, asso-
ciated with depression. Its good advice for GPs that if
you see someone with chronic physical symptoms who
doesnt have cancer or heart disease or thyroid, think
depression. We know that most GPs do just that, on
the occasion that they dont, it is usually because the
patient doesnt say, Doctor, Ive got chest pains and I fell
miserable, its because the patient simply says my chest
hurts. Sometimes, it is true, that in some circumstances
doctors fnd it harder to remember to ask about mood,
anxiety and so on, but usually they do. That brings us into
the territory of somatisation, the patient who presents
the physical symptoms with whom there is a psychiatric
disorder.
Thats some facts, there are also some myths. Myth
number one: somatisation is unusual, or rare, or abnor-
mal - it is not. It is completely common, it is perfectly
normal and we all do it. To present with the physical
symptom is the commonest way for people to present
to their doctors for psychological disorders, it is a
normal and adaptive thing to do. If I developed chest pain
today, Im still at the age where its just about more
likely that I have panic disorder than ischaemic heart
disease, although unfortunately that state of affairs is
changing. But nevertheless, when Im still at that age, it is
sensible of me to present with my chest pain because,
if it is ischaemic heart disease, that could kill me in the
immediate future, so its quite realistic and normal to
worry about having physical disease when you present
with physical symptoms. Its also what doctors want to
hear, doctors believe they are put on earth to deal with
physical illness and physical diseases.
So it is common in many ways, unexplained physical
symptoms are the norm here. Looking now at the pres-
ence of fatigue and so on in the community, but just
reminding you that physical symptoms such as fatigue
are extremely common, so therefore it is not surprising
that people present with these common symptoms. But,
equally, we should remember on the whole, when people
do, they are rarely associated with diagnosable organic
diseases in looking at the proportion of symptoms that
are explained by good standard things that doctors like.
So, if you have chest pain how much is due to heart
disease, how much isnt.
Understanding
Mental Health
2001 depression.org.uk
site design and implementation - Octopus Associates Ltd. www.oal.co.uk
SOMATISATION OF DEPRESSION
Prof. Simon Wessely
Lecture at the Royal Society of Medicine 29th October 1999
Information Center
In our hospital we looked across all the medical speciali-
ties to have a look at how many of the people presenting
from their GPs referred to our physicians with new onset
had unexplained physical symptoms it is extremely
common. 53% of those seeing a cardiologist, for example,
had not had symptoms that were referable to cardiac
disease. So the advice I often give medical students is this:
if you want to specialise in depression and anxiety, do not
do psychiatry, do cardiology because thats were youre
going to see a lot more than if youre in mainstream
psychiatry.
Myth number 2: smart, cultural, sophisticated people who
live in Western societies do not somatise, it is the more
primitive people, in the Third World that do. That is a very
common belief and reminds me very much of one of my
favourite editorials in the BMJ. It was in 1913 and it was
about Freud, not my favourite person, but nevertheless,
an editorial about the rise of Freudian ideas. The editorial
said, this kind of thing is perfectly alright for excitable
foreigners, but we are British, thank God. In the WHO
study of primary care doctors that Dr Ustun has already
mentioned, the highest rates of somatisation in the entire
world were found in South Manchester. Indeed, looking
at my own practice, the person I recall as the most
intractable, diffcult patient, the hardest to make any link
between the turmoil of his domestic life, which was
considerable and his physical symptoms, was a psycho-
therapist from Hampstead. Somatic distress is the most
common expression of emotional distress in the world,
all over, from culture to culture.
Now it is true that certain populations, for example,
immigrant populations do have high rates of what
appears to be somatisation. My wife is a GP in Ken-
nington, they now have 700 refugees from Kosovo in
their practice and she tells me that they do indeed
present regularly with physical symptoms and its a prob-
lem. Immigration brings with it immense social upheaval,
dislocation, fnancial misery and so on, on a vast scale.
There are cultural differences and Arthur Kleinman
showed very clearly an example of the kind of social
context of somatisation in China when the madness of
Mao was at it most rampant and every Chinese person
was painfully aware they were living in a perfect society.
Hence to express dissatisfaction, unhappiness or misery
became a political act and of course, in that case, people
would tend to develop physical symptoms rather than
run the risk of the problems of being psychologically
unhappy. So there we see another use of somatisation
as a form of communication in cultures at times when
communication becomes diffcult. It is not characteristic
of a particular ethnic group it, is a thing that people do at
certain times, in certain context.
Myth number 3: the physical symptoms of depression
are indeed psychological, in other words, they are all in
the mind. Complete and utter rubbish this one, utter
rubbish, there are plenty of extremely good reasons why
people with psychological disorders experience physical
symptoms. Physicians dont talk about them, dont study
them very much, but they are there. The point Im
making here is the physical symptoms of psychiatric dis-
order are exceptionally real, they are experienced as real
and they are often due to defnable, explainable, measur-
able, physiological processors. So physical symptoms are
not all in the mind.
Then our fourth myth: people express themselves as
physical symptoms because they are unable to experi-
ence emotions. This is linked to my second myth of
practice that only foreigners do this. This myth is based
on the view that people have a limited view of emotions
and hence, rather than experience the depression and
anxiety and so on, it tends to be expressed by the
agency of their body. In fact the opposite is true, physical
and psychological symptoms go together, like a horse
and carriage. One of the strongest fndings in the whole
of psychiatric epidemiology is, the more we have of one,
the more we have of the other. Once again, I know
of no exception to this rule. Physical symptoms and
psychological symptoms go together. It is not true
that if you have a tendency to experience a lot of
physical symptoms, you experience less psychological
symptoms and vice versa. Of course, some people may
be reluctant to admit symptoms that they personally
regard as shameful or distressing, thats a completely
different thing. I see this all the time in clinical practice,
people are often ashamed to say they have mood disor-
der or anxiety disorder and so on and tend instead to
emphasise the physical side of their presentation. That
is not to say they do not experience emotions. Many
of my patients have the richest emotional life you could
possibly imagine, they are just rather reluctant to engage
in this because they feel if they do so, I, as a representa-
tive of doctors, will stop taking them seriously. This is,
of course true, not about me, but sadly true about many
doctors.
That leads me to the fnal reason or perhaps, I think,
the core reason why people somatise and its about the
stigma of psychiatric disorders. Im going to use to make
page 2
Understanding
Mental Health
2001 depression.org.uk
site design and implementation - Octopus Associates Ltd. www.oal.co.uk
SOMATISATION OF DEPRESSION
Prof. Simon Wessely
Lecture at the Royal Society of Medicine 29th October 1999
Information Center
this point chronic fatigue syndrome and I do so in the
assurance and knowledge this may well lead to trouble.
Im doing so, not because chronic fatigue syndrome, CFS,
is a form of depression thats not true, but its really
because I want to show the extremes that people will
go to. In particular, I want to show the extremes to
which doctors will go to deny the possibility of a link
between CFS and depression because of the stigma
of depression. This would be the one reason I would
choose to nominate above all why people present the
physical symptoms they express at the expense of the
psychological. Here we have The Sunday Times, an article
on chronic fatigue syndrome. The consultant physician
who specialises in this disorder, told us that people with
chronic fatigue syndrome or any other similar disorder,
often have to put up with a lot of disbelief. There
are many doctors who diagnose this as a psychiatric
disorder, although, on the whole, it is taken much more
seriously now. This is The Observer, a doctor working
in London, in neurological practice, said it is important
that psychiatric patients are separated from ME because
some neurotic patients devalue the tale of genuine suf-
fering. On the other side of the same coin, this is making
the same point, a physician hostile to ME, who, talking to
other newspapers says, this ME is an imaginary disease
for which the best treatment is psychiatric. Curious
thing that really, isnt it curious! Here we have the medi-
cal adviser to the ME Association himself, it may not be
a psychiatric problem.
Ive no problem with the fact that chronic fatigue syn-
drome or whatever youre going to call it really does
exist, thats what my clinical practice is all about, thats
what I do for a living. What I object to, of course, is that
it exists at the expense of psychiatric problems which do
not exist, thats the view I fnd offensive. Here we have
another doctor, this is in Harpers & Queen, a magazine
that the British of the richer classes are familiar with,
here is another doctor, the president of the ME Asso-
ciation and a consultant microbiologist talking about
the difference in depression and ME/chronic fatigue
syndrome. It says and I quote here, ME people are
highly motivated achievers. They have almost too much
willpower, whereas depressives have virtually none.
Straightforward depression then is a failure of willpower,
its about will, it couldnt really be more clear.
So we should notice that the example that Ive used is
not a patient talking, its a doctor. Funnily enough, when
we actually asked ME patients who came to our clinic
they were not more hostile to mental illness than all
the control groups that we looked at, thats not saying
very much because everyone is hostile to mental illness.
But there was nothing different about ME patients than
everyone else, these were doctors talking. Its a sad
and inescapable fact that our diagnoses, including those
of depression, are indeed moral and value judgements.
Psychiatric explanation can be a way of blaming patients
for their illness and increase their suffering. Now you
and I know how silly that is, we know that depression is
a biological illness, just like many others.
In real life, then, many patients cant afford to be
depressed. Another of my patients recently was refused
his insurance beneft because his policy excluded depres-
sion for which he had a history. He said he was suffering
from ME - now this was rejected by the insurance
company but he was informed in a letter that this deci-
sion would be changed if a test for ME were to be
developed and he tested positive. Sufferers, then, cant
afford to be depressed just morally or symbolically, but
literally as well. Many people have imaginary diseases
then, no wonder that people somatise. My favourite
referral of all time when I was at Queens Square was
this, it said, Dear Simon, please see this patient, theres
nothing wrong with her. This is magic, I see the patient
and theres nothing wrong with her. No wonder people
dont want to come to see us, not surprising.
Weve said there are various explanations for somatiza-
tion the research into why people somatise is very
complex. They way they were brought up as children
can be important. We have a study coming out showing
people who somatise in later life come from families
in which the mother was more likely to have physical
illness, suspecting then that parents teach a child to
express things in similar ways to themselves. They take
the child to doctor more often as a kid when they were
3, 4, or 5. At 35 years we fnd that those children grown
up as adults are more likely to have physical symptoms.
We showed the same with a 30 year study of children
with abdominal pain. So there are many reasons then
why people somatise, there is a psychological basis to it,
its well worked out and its fascinating.
I also want to draw your attention to another reason
why people somatise. This is because of the increasing
amount of concerns about the environment and the
physical illness that we all have.
Im going to talk now about the role of medicalisation in
modern life and how that has impacted on somatisation.
page 3
Understanding
Mental Health
2001 depression.org.uk
site design and implementation - Octopus Associates Ltd. www.oal.co.uk
SOMATISATION OF DEPRESSION
Prof. Simon Wessely
Lecture at the Royal Society of Medicine 29th October 1999
Information Center
page 4
One of the themes of this conference is the increasing
burden of depression, youve seen the fgures and so on.
But the saying is actually true of somatic symptoms in
general, it isnt just depression, its symptoms in general
that are on the rise - we are getting sicker, at least
we feel were getting sicker. People experience more
symptoms than they did 30 years ago, 50 years ago, even
100 years ago, they have more symptoms and thats an
extraordinary thing. People living in London 100 years
ago had a life expectancy of 35, nevertheless in surveys
that were done they had less physical symptoms than
they do now, living in 1999. Americans now spend more
days in bed than they used to, I dont know how one
could work that out, but, anyway, thats a great study,
isnt it! The healthiest society of all, is California, which
is also the most health-obsessed, they have the most
physical symptoms. About 10% of the population believe
they have chemical sensitivity and they have highest rates
of spending days in bed.
In other words, were into this paradox of health that, as
we get healthier, we feel sicker and this happening across
the globe. There are epidemics of symptoms - back pain,
headaches and so on. There are complex symptoms -
sick building syndrome, chemical sensitivity, RSI, so on
and so forth, which are occurring in the developed and
possibly even the under-developed world, as well. We live
in an era now in which wherever you look, you dont
have to be bad to live an impure life, pollution lurks in
everything. So, we believe were surrounded by risk. All
we have to worry about is the water we drink, the air
that we breathe and the food we eat, apart from that
life is perfectly safe. But its about a world now in which
people are growing up where hazard is everywhere,
even everyday objects in the house clocks, the radio,
television, the electric blanket, the mobile phone - what a
killer! So again and again we are surrounded by risk. Even
when you think youre okay, youre not okay because
your allergies could be hidden. There is an epidemic now
of symptoms in general, not just depression, all of these
things are vastly on the increase as we are constantly
admonished that everything we consume, everything we
do and everything we interact with has health conse-
quences. Daily life provides fertile soil in which this
obsession with healthcare can take root. So, no wonder
then that people somatise.
To conclude then, somatisation always, but always, associ-
ated with physical symptoms and although all physical
symptoms are not due to depression, quite often they
are the physical symptoms of depression, which is not
all in the mind. When people say they feel pain, they do.
Somatisation is a common way for people to present
with psychological problems, it is a perfectly normal,
effective and sensible thing to do. Its not just things
that funny foreigners do, its a normal way and probably
an adaptive mechanism we all have. We do it because
physical symptoms are a way of expressing distress, a
way of being genuinely concerned about our health. They
are also a way of interacting in social situations where
other ways have been denied us. We have to be careful,
Im actually worried myself that we are not doing as
much about it as we should. Im worried, in particular,
that psychiatry is rapidly abandoning any claim to deal
with depression and somatisation in general. Theres a
danger that were going back to our roots in which
psychiatry just sees people who hear voices and the rest
can be dealt with by a the trained counsellor. This is a
thing thats happening in healthcare and psychiatric care,
certainly in Britain and other cultures as well and it is
very worrying indeed.
Who then are the somatisers? I conclude by pointing the
fnger at us doctors, we are somatisers and we live in the
dualistic world in which theres physical and psychologi-
cal illnesses, where theres real and unreal illness, there
are shirkers and the really sick. But as research doctors
fnally prove shirkers really are sick, pretty clear isnt it?
Which would you rather be - would you rather be a
shirker, then you can come and see me, thats okay, Im
a psychiatrist, or would you rather be sick, then you go
and see the virus research doctor. Oh and here he is, the
virus doctor, very famous one, in his white coat with a
stethoscope, you wouldnt mistake him for a psychiatrist,
would you, absolutely not. A friend of mine is looking for
the virus that causes ME/chronic fatigue syndrome. He
hasnt found it yet as I dont think anything that complex
is going to be caused by anything that simple, but thats
irrelevant, so long as our virus research doctor is on
the case, what is he delivering? Well, look, it says here
that fatigue syndrome gains doctors respect, so our virus
research doctor could deliver respect. Unfortunately,
when a patient is referred to a psychiatrist like me, what
can they expect? Thats why people somatise.