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Predictive factors for somatization in a trauma sample

Predictive factors for somatization in a trauma sample Background: Unexplained somatic symptoms are common among trauma survivors. The relationship between trauma and somatization appears to be mediated by posttraumatic stress disorder (PTSD). However, only few studies have focused on what other psychological risk factors may predispose a trauma victim towards developing somatoform symptoms. Methods: The present paper examines the predictive value of PTSD severity, dissociation, negative affectivity, depression, anxiety, and feeling incompetent on somatization in a Danish sample of 169 adult men and women who were affected by a series of explosions in a firework factory settled in a residential area. Results: Negative affectivity and feelings of incompetence significantly predicted somatization, explaining 42% of the variance. PTSD was significant until negative affectivity was controlled for. Conclusion: Negative affectivity and feelings of incompetence significantly predicted somatization in the trauma sample whereas dissociation, depression, and anxiety were not associated with degree of somatization. PTSD as a risk factor was mediated by negative affectivity. patients are real and whatever the cause, such symptoms Background People exposed to trauma often suffer from a variety of are highly debilitating. Traditional medical treatment is psychological symptoms including anxiety, depression, often not effective in helping people with somatoform and most importantly the psychiatric diagnoses of acute symptoms. In order to guide the search for more effective stress disorder (ASD) and posttraumatic stress disorder therapies, it is important to examine what causes these (PTSD). On top of this, many trauma types cause physical symptoms. In this article we want to examine the predic- injuries that may cause lifelong suffering. However, even tive effect of different potential risk factors on somatiza- trauma victims that have not been seriously injured often tion in order to shed more light on what leads to report more somatic symptoms than do control groups unexplained somatic symptoms in trauma survivors. not exposed to trauma. Such symptoms can be extremely disabling and are often a great source of psychological dis- Somatization tress – partly due to the inability of health professionals to Somatization refers to the development of somatic symp- find any physical cause for the symptoms. Thus, the symp- toms for which no organic cause is found [1,2]. Such toms are often assumed to be caused by psychological symptoms are called somatoform. The DSM-IV [3] con- processes and the patient is often dismissed by the health tains a diagnosis of somatization disorder which is given care system. However, the pain and suffering of such to people with a history of at least 8 different symptoms Page 1 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 including at least four pain symptoms, two gastrointesti- abridged somatization whereas the risk for new PTSD nal symptoms, one sexual symptom and one pseudo neu- cases was not elevated in people with a history of abridged rological symptom not fully explained by a known somatization. The Andreski et al. study thus supports the general medical condition. The low prevalence of somati- hypothesis that psychological stress caused by PTSD may zation in study samples has led researchers to use the less increase personal vulnerability towards experiencing restrictive concept of abridged somatization, defined as somatic symptoms. the occurrence of at least 4 somatoform symptoms in men and 6 in women [4]. In contrast to this categorical Risk factors approach, somatization is often considered to represent a In a disaster study by North, Kawasaki, Spitznagel, and continuum with few symptoms at one end and multiple Hong [2], the prevalence of new somatoform symptoms symptoms relating to various body sites at the other [5]. following a traumatic event was found not to be associ- Unless anything else is stated, throughout this article we ated with gender, injury or property damage. Also, no will refer to somatization as a spectrum of somatoform association was found between the number of physical symptoms of varying degrees. symptoms and intensity of exposure to trauma [11]. Therefore, we have chosen to focus on posttraumatic and Somatization following trauma personality factors which may mediate the relationship Somatoform symptoms have consistently been linked to between trauma and somatization. traumatic exposure. Trauma victims tend to score higher PTSD symptom clusters on self-reports of somatic complaints compared to con- trols [2,4,6-11]. It has been suggested that neurobiological As mentioned, PTSD has repeatedly shown to be the most changes, increased physiological arousal, and poorer important predictor of somatization in trauma samples health behaviour in the aftermath of trauma paves the but it does not appear that the three symptom clusters of way for somatization [12]. Furthermore, somatization PTSD predict somatization equally well. McFarlane et al. may be related to other psychological consequences of [11] found that only the intrusion subscale achieved sig- trauma such as depression, anxiety, dissociation, and nificance when using the different PTSD clusters to predict PTSD. somatization. Intrusion may correlate with somatization because both are results of the disturbed information Van der Kolk, Pelcovitz, Roth, Mandel, McFarlane, and processing that is often present in PTSD, making it diffi- Herman [13] point out that somatoform symptoms, dis- cult for the victims to distinguish relevant from irrelevant sociation, and symptoms now present in the DSM-IV information [11]. Contrary to this finding, Escalona, diagnosis of PTSD [3] were originally combined in the Achilles, Waitzkin, and Yager found PTSD numbing psychoanalytical concept of hysteria which was consid- symptoms to be better at predicting somatization than the ered to be related to traumatic exposure [6]. They argue other avoidance symptoms as well as intrusion and that the DSM-IV diagnosis of PTSD is too narrow to ade- arousal symptoms [1]. According to David Spiegel the quately capture all these symptoms which are more often numbing criteria defined by DSM-IV as a sense of isola- than not coexisting in the aftermath of trauma. A similar tion from others is consistent with a dissociated self- point has been made by Brown, Cardeña, Nijenhuis, Sar, image [18]. Therefore these results may be due to dissoci- and Van der Hart [14]. In line with this view, several stud- ation increasing the risk of somatization. ies have found that this relationship between trauma and somatization is mediated by PTSD [2,11,15,16]. PTSD Dissociation patients who report physical symptoms also report higher It has been suggested that somatoform symptoms are overall PTSD symptoms [6,17] and a higher frequency of caused by the dissociation of distressing material from depression [10,17] than PTSD patients who do not report conscious awareness caused by traumatic experiences in such physical symptoms. The relation between PTSD and childhood [18]. More recently it has been suggested that somatization may be explained by a lowered responsive- physical symptoms in patients with PTSD may be a form ness towards external stimuli combined with an increased of somatoform dissociation defined as the partial or com- awareness of internal stimuli which has been found in plete loss of normal integration of somatoform compo- people suffering from PTSD [11]. nents of experience, reactions, and functions [19]. Somatoform dissociation correlates highly with psycho- The correlation between PTSD and somatization does not logical dissociation and both are common in patients tell us whether PTSD causes the somatic symptoms, with PTSD [20]. In fact, dissociation has been suggested to whether the somatic symptoms cause PTSD, or whether be responsible for many of the most severe consequences the somatic symptoms and the PTSD symptomatology are of PTSD [21]. Patients with dissociative disorders as well both caused by a third variable. Andreski, Chilcoat, and as PTSD patients present more somatoform symptoms Breslau [4] found that PTSD increased the risk for than other psychiatric patients [19,22]. Therefore, several Page 2 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 researchers have investigated whether dissociation some- A part of the definition of negative affectivity is that it how mediates the relationship between PTSD and soma- should make people more prone to experience somato- tization. form symptoms. It is therefore not unexpected that several studies have shown neuroticism/negative affectivity to be Punamäki, Komproe, Quota, Elmasri, and de Jong found implicated in somatization [4,5,27,28,30]. Negative affec- that peritraumatic dissociation did not have any mediat- tivity has shown to correlate highest with non-specific ing effect on the relationship between trauma and somatic symptoms such as stomach ache compared to more local symptoms [23]. In contrast, Salmon, Skaife, and Rhodes and specific symptoms [31]. It has been suggested that found that in patients with irritable bowel syndrome neuroticism/negative affectivity serves as a risk factor for (IBS) persistent dissociation appeared as a mediating fac- both PTSD and somatization [4] and that it may thus tor in the relationship between trauma and somatization mediate the relationship between the two variables. How- [24]. It is thus possible that persistent but not peritrau- ever, to our knowledge, no study has examined the predic- matic dissociation predicts somatization. However, tive value of negative affectivity on somatization Salmon et al. did not control for PTSD and it is possible specifically in a trauma sample and therefore it is not that if that had been done, it would have caused dissocia- known how important negative affectivity is compared to tion to lose significance [24]. trauma related factors such as PTSD and somatization. Depression and anxiety Self-esteem/self-efficacy and related concepts Somatization has been found to be related to high levels Studies have shown that people with PTSD often have of psychological distress, anxiety and depressive diag- lowered self-esteem. The causality in this relationship has noses and functional impairment [5]. Previous studies not been very well studied but it probably goes both ways. have shown mood and anxiety disorders to be good pre- Wong and Cook found that PTSD led to lower self-esteem dictors of somatization [25]. However, this may be due to and feelings of shame [32], whereas Adams and Boscanno the fact that many of these studies have not assessed found that low self-esteem significantly predicted PTSD PTSD. As both depression and anxiety disorders are fre- [33]. The role of self-esteem and related concepts in soma- quently comorbid with PTSD, their correlation with tization is not well examined either, but one study by Böd- somatization may be dependent on the relationship varsdóttir and Elklit found that low self-worth was related between PTSD and somatization. to the development of somatic symptoms as well as PTSD following two Icelandic earthquakes [34]. The direction of Escalona et al. [1] studied women attending a primary the relationship, however, was not clear. In relation to this care clinic at a department for Veteran Affairs and found finding, Murphy found that self-efficacy significantly pre- that demographic variables as well as generalized anxiety dicted somatization explaining 10% of the variance in disorder (GAD), panic disorder, and depression all failed survivors of the Mount St. Helens eruption [35]. Although to significantly predict somatization when PTSD was con- these different concepts are not identical, the findings trolled for. Also, in a study of combat veterans by Beck- combined do suggest that being self-confident may be a ham et al. [17] depression did not significantly predict protective factor, whereas being conscious of one self and number of somatic complaints. Contrary to this, other one's body may heighten the risk for somatization. studies have found depression and anxiety to be signifi- cant predictors of somatization, even when PTSD is con- Methods rd trolled for [2,11,26]. In the afternoon of November 3 2004 a series of explo- sions hit a firework factory in Seest, a suburb of the Dan- Negative affectivity ish city Kolding. One fireman was killed, about half a The overlapping constructs of negative affectivity and neu- dozen residents were injured and 261 homes were partly roticism are included in many factor models of personal- or completely destroyed. The explosion measured 2.2 on ity including Costa and McCrae's five factor model of the Richter scale and the costs of the disaster exceeded 100 temperament where they are defined as the propensity to million €. Most of the residents of the area were evacuated experience a wide variety of somatic and emotional dys- and many were unable to contact family members to phoric states including depression, anxiety, anger, and make sure that they were safe. In average, people came somatic symptoms [27]. People who score high on neu- into contact with their families after 2 1/2 hours but in roticism are characterized by an inability to cope effec- one case family members were unable to come into con- tively with stress [28] and neuroticism and negative tact with each other for three days. 51% of the sample had affectivity have been shown to play a role in the develop- their home either partially or completely destroyed by the ment of PTSD as well as other psychiatric disorders [7,29]. explosions. Those who still had a home returned after an average of 4 1/2 days. Further information has been pub- lished elsewhere [36]. Page 3 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 Procedures Statistics PTSD, somatization and a number of other variables were The following results are based on somatization measured ) was three and the independent variables measured at T . Mean measured at two time points. The first (T at T 1 2 1 months after the accident and the second (T ) was one values and standard deviations are given for each meas- year later. Details of design and sampling have been ure. accounted for elsewhere [36]. Multiple linear regression analyses were used to assess the 516 people (51% women, 49% men) participated in the predictive values of the different independent variables on study at T . The data in the present study are from the 169 somatization. When the predictive value of each measure participants who answered the somatization question- had been established the significant values were entered naire at both T and T . Ages ranged from 18 to 95 years into a regression analysis together in order to establish 1 2 with a mean age of 50.2 years (SD = 14.7). which values were still significant. A p-value of .05 was used to establish significance. Measures � The Harvard Trauma Questionnaire part IV (HTQ) Results measures PTSD severity and estimates PTSD diagnosis The mean score for somatization at T was 17.8 (SD = 5.6) according to the DSM-IV [37]. The HTQ contains 32 items ranging from 11 to 38. At T the mean total HTQ score was based on the three subscales of PTSD concerning a poten- 51.4 (SD = 13.5). The participants scored highest on the tially distressing event. The answers are scored on a four- avoidance subscale (M = 10.7, SD = 36), followed by the point Likert scale ("not at all" (1), "a little" (2), "quite a arousal subscale (M = 10.1, SD = 3.8), and the intrusion bit (3), "all the time" (4)). The HTQ has good internal subscale (M = 9.3, SD = 3.0). It was estimated that approx- consistency, test-retest reliability and concurrent validity imately 13% of the participants met criteria for a PTSD [37]. The alpha value for the total HTQ score was .93 in diagnosis and 27% had sub-clinical PTSD, missing only this study. one symptom in having a full PTSD diagnosis. � The TSC was originally created by Briere and Runtz [38]. The sample that completed the questionnaire at both time A Factor analysis has identified three subscales relating to points scored slightly higher on some of the measures somatization, negative affectivity and dissociation [39]. than those who only completed the questionnaire at T1. The somatization subscale consists of 8 items relating to Significant differences were found for negative affectivity, headaches, stomach aches, respiratory problems and dissociation, reexperiencing, avoidance, and HTQ total other non-specific somatic symptoms. Items are rated on score (all ps ≤ .05). No significant differences were found a 4-point Likert scale ranging from "no" to "very often". for gender, age, anxiety, depression, and feelings incom- The revised TSC has good reliability and good factor and petence. criteria validity [39]. The alpha values in this study after PTSD three months were .82 for somatization, .85 for negative affectivity, and .63 for dissociation. The three HTQ symptom clusters were entered into a lin- ear regression analysis. Together they explained 33% of � The General Health Questionnaire-30 (GHQ-30) is the variance but only the arousal factor was significant. based on the original 60 items edition of the GHQ [40]. When the two clusters of intrusion and avoidance were In the GHQ-30 the somatic subscale has been removed removed from the model, arousal alone explained 34% of and the items have been reduced to 30 [41]. The GHQ-30 the variance (F = 86.22, p ≤ .005). therefore measures mainly psychological and psychoso- Depression, anxiety, and feeling incompetent cial symptoms spread across five subscales measuring anx- iety, feeling incompetent, depression, social dysfunction, At T the mean score on the depression subscale of the and coping failure. Items are rated on a 4-point Likert GHQ-30 was 7.8 (SD = 2.4). The mean score for anxiety scale rating from "a lot worse than usual", "worse than was 16.4 (SD = 5.1), and for incompetence it was 12.5 usual", "same as usual" to "better than usual". The sensi- (SD = 1.8). Depression, anxiety and incompetence all had tivity and specificity of the GHQ is estimated to be 81% significant and moderate correlations with somatization and 80%, respectively [40]. The alpha value for the total at T (all rho's ≥ .38, all ps ≤ 0.001). All three variables were GHQ-30 score in this study was .91. For depression the entered into a regression model but only anxiety and feel- alpha value was .83, for anxiety it was .91, and for feeling ing incompetent made a significant contribution. incompetent it was .71. Together these two risk factors accounted for 33% of the variance in somatization (F = 40.81, p ≤ .05). Page 4 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 Table 2: Final model. Negative affectivity and dissociation At T the mean score on dissociation was 6.1 (SD = 1.6) Beta Significance and the mean score on negative affectivity was 13.5 (SD = 3.8). Dissociation correlated moderately with somatiza- GHQ incompetence .27 ≥ .001 tion at T (rho = .40, p ≤ 0.01) while the correlation TSC negative affectivity .45 ≥ .001 between negative affectivity and somatization was high (rho = 0.62, p ≤ .001). The dissociation and the negative Note: Adjusted R square = .42 F = 57.44 affectivity subscales from the revised TSC were analyzed Final regression analysis with the revised TSC somatization subscale using linear regression. Alone, dissociation was signifi- as dependent variable and incompetence and negative affectivity as cant, but it failed to remain so, when negative affectivity independent variables. was introduced. Negative affectivity, however, was highly significant and explained 37% of the variance (F = 95.77, entirely to significantly predict somatization after negative p ≤ .005). affectivity was controlled for. Combination of significant risk factors Also contrary to previous findings, we found that arousal As a final step, all the significant measures were entered was the only PTSD symptom cluster to significantly pre- into a regression model together. When the risk factors dict somatization (although only until negative affectivity were entered together only negative affectivity reached sig- was controlled for). We did not examine numbing inde- nificance and feeling incompetent almost did (Table 1). pendently from the other avoidance symptoms, as was We tested the predictive value of PTSD severity one last done in the Escalona et al. study, so we do not know time by making a two-step regression analysis. At the first whether numbing alone would have been significant. In step we entered feelings of incompetence together with relation to the other study mentioned earlier, McFarlane HTQ total score. They were both highly significant (both et al. used the IES to measure PTSD and thus did not ps ≤ .001) and together predicted 36% of the symptom measure arousal. However, they did point out that the car- variance. However, when negative affectivity entered the diovascular, respiratory, and neurological symptoms that model at step two, HTQ total score completely lost signif- patients with PTSD often complain of are consistent with icance leaving only feelings of incompetence and negative physical symptoms of arousal. Following this line of affectivity as significant predictors of somatization (both thought it should not be surprising that the arousal cluster ps ≤ .001). Together these two measures accounted for in this study has proven to be a better predictor of soma- 42% of the total somatization variance (Table 2). tization than both intrusion and avoidance/numbing. However, even the arousal cluster of the HTQ did not remain significant when negative affectivity and feeling Discussion We did not in this sample find support for the hypothesis incompetent were controlled for. that dissociation and PTSD should be particularly related to somatization as suggested by Van der Kolk et al. [13]. There are a few possible explanations for why PTSD and Consistent with the finding by Salmon et al. [24], dissoci- dissociation failed to ultimately predict somatization in ation was a significant predictor of somatization but only this study. One possibility is that negative affectivity until negative affectivity was controlled for. Even more mediates the effect of PTSD on somatization. This hypoth- surprisingly, and contrary to the findings from the studies esis is supported by the fact that PTSD lost significance mentioned in this article, PTSD did not emerge as the when negative affectivity was controlled for. However, most important risk factor. In fact, PTSD severity failed another possibility is that the three concepts of dissocia- tion, posttraumatic stress, and somatization are only con- Table 1: significant risk factors. nected following more intrusive traumas such as childhood sexual abuse or perhaps adult rape or torture. Variable Beta Significance It is thus possible that both dissociation and PTSD would HTQ arousal .15 n.s. emerge as significant risk factors in such trauma samples GHQ anxiety .09 n.s. even after controlling for negative affectivity. This hypoth- GHQ incompetence .16 .053 esis is supported by the finding that exposure to natural TSC negative affectivity .32 .002 disasters (which has some features in common with the CSS feeling let down .06 n.s. industrial disaster that the sample in the present study had been subjected to) tends to be associated with PTSD but Note: Adjusted R square = .42 to be less related to somatization, dissociation, and affect F = 22.73 n.s.: not significant dysregulation than for example child abuse [13]. Last but New regression analysis with the revised TSC somatization subscale not least, dissociation and PTSD were measured at three as dependent variable and the previously significant measures as months in order to better establish a causal relationship independent variables. Page 5 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 between the two measures and somatization. However, if ing attempts. However, this relationship probably works dissociation and PTSD are not just risk factors but part of both ways, and somatization is very likely to further the somatization process, somatization should correlate decrease self-esteem and lead to feelings of incompetence. with dissociation and PTSD at T but not necessarily twelve months earlier. Therefore, the results do not show It is not as unexpected that we found negative affectivity whether dissociation and PTSD are involved in the proc- to be highly predictive of somatization, as this is in line ess of somatization but only that persistent psychological with studies on non-traumatised samples. However, it is dissociation and symptoms of posttraumatic stress meas- very interesting that we found negative affectivity to medi- ured three months after an industrial accident affecting a ate the effect of PTSD on somatization to such an extent residential area do not appear to explain the variance in that HTQ total score as well as the arousal sub-scale score somatization twelve months later above and beyond what failed to significantly predict somatization. As no other can be explained by negative affectivity and feeling study to our knowledge has controlled for negative affec- incompetent. tivity when examining somatization in a trauma sample, this important finding can neither be supported nor con- Depression and anxiety measured by the GHQ did not tradicted by other research. fare any better than PTSD and dissociation at predicting somatization. Whereas depression did not reach signifi- It has been proposed that trait negative affectivity has a cance even when first entering the analysis, anxiety was general non-specific relationship with symptom report- originally significant but failed to remain so after feelings ing, suggesting that people high on negative affectivity are of incompetence, arousal, negative affectivity, and feeling interoceptively hypervigilant and thus notice bodily let down were controlled for. This is probably due to neg- changes that go unnoticed in other people [31]. Another ative affectivity mediating the relationship between anxi- way through which negative affectivity may influence ety and somatization. As the definition of negative reporting of somatic symptoms is through recall bias affectivity is partly based on the tendency to experience caused by state-dependant recall [41]. Furthermore, neu- fear and anxiety it is not surprising that there should be roticism/negative affectivity may increase the actual prev- some overlap between the two concepts. It is intriguing alence of somatic symptoms through risk behaviours such that anxiety proved a better predictor of somatization as smoking, drinking, and using drugs [28]. Also, studies than did depression. As mentioned earlier, studies have have shown that people who score high on neuroticism generally found depression to be a better predictor of tend to have poor eating, sleeping, and exercise habits somatization than anxiety. This unexpected finding may [28]. be related to the use of an instrument that is not specifi- cally designed to measure the two variables. Negative affectivity is not uniquely associated with soma- tization but appears to be a general predictor of symp- In contrast to all these variables, feeling incompetent and tomatology. This is probably the reason why it appeared negative affectivity did significantly predict somatization to mediate the effect of both PTSD, dissociation, and anx- in this sample, together accounting for 42% of the iety on somatization in this study. Furthermore, negative somatoform symptom variance. As for feeling incompe- affectivity is related to somatization even in the absence of tent, it is quite interesting that a psychological measure a traumatic stressor. This study therefore suggests that that has been so little in the focus of research, actually even though somatization is particularly prevalent in trau- proved better at predicting somatization than did other- matised populations, the mechanisms behind traumatisa- wise well-established risk factors. What is really interest- tion do not appear to differ between traumatised and ing is that feeling incompetent was actually the only single general populations. (although it should be noted that a factor that remained significant when negative affectivity general population is not necessarily traumatised). Thus, was controlled for. This is despite the fact that such a even though PTSD and dissociation appear to be associ- measure of low self-esteem/self-efficacy could well be ated with degree of somatization in the aftermath of hypothesized to be mediated by negative affectivity as trauma, they do not surpass the importance of negative well as by PTSD. As the GHQ measure was taken at T affectivity as a non-specific risk factor of somatization. while somatization was measured at T , these results sug- gest that feeling incompetent increases the risk of somati- Limitations of the study zation, possibly by influencing the person's attempts to There are several limitations to this study. Most impor- cope with the traumatic event as well as with any somato- tantly, the use of combined measures was made necessary form symptoms. According to Murphy et al. [35], whether by the high number of variables examined, as more thor- a person engages in coping attempts depends on the ough testing of each single variable would have made the expectations he or she has concerning their success and questionnaire too time consuming for the participants. expecting failure may decrease the effect of any such cop- However, the TSC and the GHQ are designed to test sev- Page 6 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 eral psychological constructs combined and may not PTSD severity do not. More guided research focusing on measure variables such as dissociation and depression as variables such as self worth and self-efficacy will give more thoroughly as an instrument designed specifically to test detailed information on how it affects somatization. such variables. For example, it can be argued that the five items of the dissociation subscale used in this study is not Finally, this study examined a sample where all partici- quite enough to make a good estimate of dissociation in a pants had been subject to the same traumatic event. It traumatised sample. Furthermore, we assessed only per- should be studied whether the same risk factors apply to sistent psychological dissociation. Thus, neither peritrau- somatization after other trauma types – especially after matic nor somatoform dissociation will be revealed using more personal traumas such as torture, physical assault, or the revised TSC. Though persistent/pathological dissocia- rape where victims for example tend to dissociate more. tion has been shown to correlate with peritraumatic disso- ciation [43] the two measures may not predict Conclusion somatization equally well. Contrary to what other studies have found, depression did not significantly predict somatization in this study and Another limitation is that many of the houses in the dis- nor did anxiety and dissociation after negative affectivity aster area had to undergo major repairs and some had to was controlled for. Even more interesting, PTSD did not be rebuilt completely. This is a process that takes very long significantly predict somatization after controlling for time and for some people it was further delayed by prob- negative affectivity, suggesting that negative affectivity is a lems with insurance companies [36]. This means that the more important predictor of somatization even in trauma general level of stress can be expected to be quite high due samples than PTSD. In stead, negative affectivity and feel- to practical issues, relocation, and insecurity concerning ings of incompetence significantly predicted the degree of insurance outcomes. There is a risk that these stressors somatization, together accounting for 42% of the vari- may have influenced some of the different measures. For ance. This finding is to our knowledge unprecedented. example, negative affectivity is supposed to measure a per- sonality trait, but the negative affectivity scores may have Competing interests been increased by a high level of general stress in the sam- The authors declare that they have no competing interests. ple. Authors' contributions Last but not least, the sample consisted of people from the AE carried out the studies, performed the statistical analy- same small area of similar ethnicity, cultural background, ses, supervised the writing of the article and drafted the and middle class socioeconomic status. The results found manuscript. DMC performed the statistical analyses and here cannot automatically be extrapolated to populations wrote the article. 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Soc Sci Med cited in PubMed and archived on PubMed Central 2005, 61:1835-1845. 32. Wong MR, Cook D: Shame and its contribution to PTSD. J yours — you keep the copyright Traum Stress 1992, 5:557-562. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Clinical Practice and Epidemiology in Mental Health Springer Journals

Predictive factors for somatization in a trauma sample

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Springer Journals
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Copyright © 2009 by Elklit and Christiansen; licensee BioMed Central Ltd.
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Medicine & Public Health; Psychiatry; Epidemiology
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1745-0179
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1745-0179
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10.1186/1745-0179-5-1
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19126224
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Abstract

Background: Unexplained somatic symptoms are common among trauma survivors. The relationship between trauma and somatization appears to be mediated by posttraumatic stress disorder (PTSD). However, only few studies have focused on what other psychological risk factors may predispose a trauma victim towards developing somatoform symptoms. Methods: The present paper examines the predictive value of PTSD severity, dissociation, negative affectivity, depression, anxiety, and feeling incompetent on somatization in a Danish sample of 169 adult men and women who were affected by a series of explosions in a firework factory settled in a residential area. Results: Negative affectivity and feelings of incompetence significantly predicted somatization, explaining 42% of the variance. PTSD was significant until negative affectivity was controlled for. Conclusion: Negative affectivity and feelings of incompetence significantly predicted somatization in the trauma sample whereas dissociation, depression, and anxiety were not associated with degree of somatization. PTSD as a risk factor was mediated by negative affectivity. patients are real and whatever the cause, such symptoms Background People exposed to trauma often suffer from a variety of are highly debilitating. Traditional medical treatment is psychological symptoms including anxiety, depression, often not effective in helping people with somatoform and most importantly the psychiatric diagnoses of acute symptoms. In order to guide the search for more effective stress disorder (ASD) and posttraumatic stress disorder therapies, it is important to examine what causes these (PTSD). On top of this, many trauma types cause physical symptoms. In this article we want to examine the predic- injuries that may cause lifelong suffering. However, even tive effect of different potential risk factors on somatiza- trauma victims that have not been seriously injured often tion in order to shed more light on what leads to report more somatic symptoms than do control groups unexplained somatic symptoms in trauma survivors. not exposed to trauma. Such symptoms can be extremely disabling and are often a great source of psychological dis- Somatization tress – partly due to the inability of health professionals to Somatization refers to the development of somatic symp- find any physical cause for the symptoms. Thus, the symp- toms for which no organic cause is found [1,2]. Such toms are often assumed to be caused by psychological symptoms are called somatoform. The DSM-IV [3] con- processes and the patient is often dismissed by the health tains a diagnosis of somatization disorder which is given care system. However, the pain and suffering of such to people with a history of at least 8 different symptoms Page 1 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 including at least four pain symptoms, two gastrointesti- abridged somatization whereas the risk for new PTSD nal symptoms, one sexual symptom and one pseudo neu- cases was not elevated in people with a history of abridged rological symptom not fully explained by a known somatization. The Andreski et al. study thus supports the general medical condition. The low prevalence of somati- hypothesis that psychological stress caused by PTSD may zation in study samples has led researchers to use the less increase personal vulnerability towards experiencing restrictive concept of abridged somatization, defined as somatic symptoms. the occurrence of at least 4 somatoform symptoms in men and 6 in women [4]. In contrast to this categorical Risk factors approach, somatization is often considered to represent a In a disaster study by North, Kawasaki, Spitznagel, and continuum with few symptoms at one end and multiple Hong [2], the prevalence of new somatoform symptoms symptoms relating to various body sites at the other [5]. following a traumatic event was found not to be associ- Unless anything else is stated, throughout this article we ated with gender, injury or property damage. Also, no will refer to somatization as a spectrum of somatoform association was found between the number of physical symptoms of varying degrees. symptoms and intensity of exposure to trauma [11]. Therefore, we have chosen to focus on posttraumatic and Somatization following trauma personality factors which may mediate the relationship Somatoform symptoms have consistently been linked to between trauma and somatization. traumatic exposure. Trauma victims tend to score higher PTSD symptom clusters on self-reports of somatic complaints compared to con- trols [2,4,6-11]. It has been suggested that neurobiological As mentioned, PTSD has repeatedly shown to be the most changes, increased physiological arousal, and poorer important predictor of somatization in trauma samples health behaviour in the aftermath of trauma paves the but it does not appear that the three symptom clusters of way for somatization [12]. Furthermore, somatization PTSD predict somatization equally well. McFarlane et al. may be related to other psychological consequences of [11] found that only the intrusion subscale achieved sig- trauma such as depression, anxiety, dissociation, and nificance when using the different PTSD clusters to predict PTSD. somatization. Intrusion may correlate with somatization because both are results of the disturbed information Van der Kolk, Pelcovitz, Roth, Mandel, McFarlane, and processing that is often present in PTSD, making it diffi- Herman [13] point out that somatoform symptoms, dis- cult for the victims to distinguish relevant from irrelevant sociation, and symptoms now present in the DSM-IV information [11]. Contrary to this finding, Escalona, diagnosis of PTSD [3] were originally combined in the Achilles, Waitzkin, and Yager found PTSD numbing psychoanalytical concept of hysteria which was consid- symptoms to be better at predicting somatization than the ered to be related to traumatic exposure [6]. They argue other avoidance symptoms as well as intrusion and that the DSM-IV diagnosis of PTSD is too narrow to ade- arousal symptoms [1]. According to David Spiegel the quately capture all these symptoms which are more often numbing criteria defined by DSM-IV as a sense of isola- than not coexisting in the aftermath of trauma. A similar tion from others is consistent with a dissociated self- point has been made by Brown, Cardeña, Nijenhuis, Sar, image [18]. Therefore these results may be due to dissoci- and Van der Hart [14]. In line with this view, several stud- ation increasing the risk of somatization. ies have found that this relationship between trauma and somatization is mediated by PTSD [2,11,15,16]. PTSD Dissociation patients who report physical symptoms also report higher It has been suggested that somatoform symptoms are overall PTSD symptoms [6,17] and a higher frequency of caused by the dissociation of distressing material from depression [10,17] than PTSD patients who do not report conscious awareness caused by traumatic experiences in such physical symptoms. The relation between PTSD and childhood [18]. More recently it has been suggested that somatization may be explained by a lowered responsive- physical symptoms in patients with PTSD may be a form ness towards external stimuli combined with an increased of somatoform dissociation defined as the partial or com- awareness of internal stimuli which has been found in plete loss of normal integration of somatoform compo- people suffering from PTSD [11]. nents of experience, reactions, and functions [19]. Somatoform dissociation correlates highly with psycho- The correlation between PTSD and somatization does not logical dissociation and both are common in patients tell us whether PTSD causes the somatic symptoms, with PTSD [20]. In fact, dissociation has been suggested to whether the somatic symptoms cause PTSD, or whether be responsible for many of the most severe consequences the somatic symptoms and the PTSD symptomatology are of PTSD [21]. Patients with dissociative disorders as well both caused by a third variable. Andreski, Chilcoat, and as PTSD patients present more somatoform symptoms Breslau [4] found that PTSD increased the risk for than other psychiatric patients [19,22]. Therefore, several Page 2 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 researchers have investigated whether dissociation some- A part of the definition of negative affectivity is that it how mediates the relationship between PTSD and soma- should make people more prone to experience somato- tization. form symptoms. It is therefore not unexpected that several studies have shown neuroticism/negative affectivity to be Punamäki, Komproe, Quota, Elmasri, and de Jong found implicated in somatization [4,5,27,28,30]. Negative affec- that peritraumatic dissociation did not have any mediat- tivity has shown to correlate highest with non-specific ing effect on the relationship between trauma and somatic symptoms such as stomach ache compared to more local symptoms [23]. In contrast, Salmon, Skaife, and Rhodes and specific symptoms [31]. It has been suggested that found that in patients with irritable bowel syndrome neuroticism/negative affectivity serves as a risk factor for (IBS) persistent dissociation appeared as a mediating fac- both PTSD and somatization [4] and that it may thus tor in the relationship between trauma and somatization mediate the relationship between the two variables. How- [24]. It is thus possible that persistent but not peritrau- ever, to our knowledge, no study has examined the predic- matic dissociation predicts somatization. However, tive value of negative affectivity on somatization Salmon et al. did not control for PTSD and it is possible specifically in a trauma sample and therefore it is not that if that had been done, it would have caused dissocia- known how important negative affectivity is compared to tion to lose significance [24]. trauma related factors such as PTSD and somatization. Depression and anxiety Self-esteem/self-efficacy and related concepts Somatization has been found to be related to high levels Studies have shown that people with PTSD often have of psychological distress, anxiety and depressive diag- lowered self-esteem. The causality in this relationship has noses and functional impairment [5]. Previous studies not been very well studied but it probably goes both ways. have shown mood and anxiety disorders to be good pre- Wong and Cook found that PTSD led to lower self-esteem dictors of somatization [25]. However, this may be due to and feelings of shame [32], whereas Adams and Boscanno the fact that many of these studies have not assessed found that low self-esteem significantly predicted PTSD PTSD. As both depression and anxiety disorders are fre- [33]. The role of self-esteem and related concepts in soma- quently comorbid with PTSD, their correlation with tization is not well examined either, but one study by Böd- somatization may be dependent on the relationship varsdóttir and Elklit found that low self-worth was related between PTSD and somatization. to the development of somatic symptoms as well as PTSD following two Icelandic earthquakes [34]. The direction of Escalona et al. [1] studied women attending a primary the relationship, however, was not clear. In relation to this care clinic at a department for Veteran Affairs and found finding, Murphy found that self-efficacy significantly pre- that demographic variables as well as generalized anxiety dicted somatization explaining 10% of the variance in disorder (GAD), panic disorder, and depression all failed survivors of the Mount St. Helens eruption [35]. Although to significantly predict somatization when PTSD was con- these different concepts are not identical, the findings trolled for. Also, in a study of combat veterans by Beck- combined do suggest that being self-confident may be a ham et al. [17] depression did not significantly predict protective factor, whereas being conscious of one self and number of somatic complaints. Contrary to this, other one's body may heighten the risk for somatization. studies have found depression and anxiety to be signifi- cant predictors of somatization, even when PTSD is con- Methods rd trolled for [2,11,26]. In the afternoon of November 3 2004 a series of explo- sions hit a firework factory in Seest, a suburb of the Dan- Negative affectivity ish city Kolding. One fireman was killed, about half a The overlapping constructs of negative affectivity and neu- dozen residents were injured and 261 homes were partly roticism are included in many factor models of personal- or completely destroyed. The explosion measured 2.2 on ity including Costa and McCrae's five factor model of the Richter scale and the costs of the disaster exceeded 100 temperament where they are defined as the propensity to million €. Most of the residents of the area were evacuated experience a wide variety of somatic and emotional dys- and many were unable to contact family members to phoric states including depression, anxiety, anger, and make sure that they were safe. In average, people came somatic symptoms [27]. People who score high on neu- into contact with their families after 2 1/2 hours but in roticism are characterized by an inability to cope effec- one case family members were unable to come into con- tively with stress [28] and neuroticism and negative tact with each other for three days. 51% of the sample had affectivity have been shown to play a role in the develop- their home either partially or completely destroyed by the ment of PTSD as well as other psychiatric disorders [7,29]. explosions. Those who still had a home returned after an average of 4 1/2 days. Further information has been pub- lished elsewhere [36]. Page 3 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 Procedures Statistics PTSD, somatization and a number of other variables were The following results are based on somatization measured ) was three and the independent variables measured at T . Mean measured at two time points. The first (T at T 1 2 1 months after the accident and the second (T ) was one values and standard deviations are given for each meas- year later. Details of design and sampling have been ure. accounted for elsewhere [36]. Multiple linear regression analyses were used to assess the 516 people (51% women, 49% men) participated in the predictive values of the different independent variables on study at T . The data in the present study are from the 169 somatization. When the predictive value of each measure participants who answered the somatization question- had been established the significant values were entered naire at both T and T . Ages ranged from 18 to 95 years into a regression analysis together in order to establish 1 2 with a mean age of 50.2 years (SD = 14.7). which values were still significant. A p-value of .05 was used to establish significance. Measures � The Harvard Trauma Questionnaire part IV (HTQ) Results measures PTSD severity and estimates PTSD diagnosis The mean score for somatization at T was 17.8 (SD = 5.6) according to the DSM-IV [37]. The HTQ contains 32 items ranging from 11 to 38. At T the mean total HTQ score was based on the three subscales of PTSD concerning a poten- 51.4 (SD = 13.5). The participants scored highest on the tially distressing event. The answers are scored on a four- avoidance subscale (M = 10.7, SD = 36), followed by the point Likert scale ("not at all" (1), "a little" (2), "quite a arousal subscale (M = 10.1, SD = 3.8), and the intrusion bit (3), "all the time" (4)). The HTQ has good internal subscale (M = 9.3, SD = 3.0). It was estimated that approx- consistency, test-retest reliability and concurrent validity imately 13% of the participants met criteria for a PTSD [37]. The alpha value for the total HTQ score was .93 in diagnosis and 27% had sub-clinical PTSD, missing only this study. one symptom in having a full PTSD diagnosis. � The TSC was originally created by Briere and Runtz [38]. The sample that completed the questionnaire at both time A Factor analysis has identified three subscales relating to points scored slightly higher on some of the measures somatization, negative affectivity and dissociation [39]. than those who only completed the questionnaire at T1. The somatization subscale consists of 8 items relating to Significant differences were found for negative affectivity, headaches, stomach aches, respiratory problems and dissociation, reexperiencing, avoidance, and HTQ total other non-specific somatic symptoms. Items are rated on score (all ps ≤ .05). No significant differences were found a 4-point Likert scale ranging from "no" to "very often". for gender, age, anxiety, depression, and feelings incom- The revised TSC has good reliability and good factor and petence. criteria validity [39]. The alpha values in this study after PTSD three months were .82 for somatization, .85 for negative affectivity, and .63 for dissociation. The three HTQ symptom clusters were entered into a lin- ear regression analysis. Together they explained 33% of � The General Health Questionnaire-30 (GHQ-30) is the variance but only the arousal factor was significant. based on the original 60 items edition of the GHQ [40]. When the two clusters of intrusion and avoidance were In the GHQ-30 the somatic subscale has been removed removed from the model, arousal alone explained 34% of and the items have been reduced to 30 [41]. The GHQ-30 the variance (F = 86.22, p ≤ .005). therefore measures mainly psychological and psychoso- Depression, anxiety, and feeling incompetent cial symptoms spread across five subscales measuring anx- iety, feeling incompetent, depression, social dysfunction, At T the mean score on the depression subscale of the and coping failure. Items are rated on a 4-point Likert GHQ-30 was 7.8 (SD = 2.4). The mean score for anxiety scale rating from "a lot worse than usual", "worse than was 16.4 (SD = 5.1), and for incompetence it was 12.5 usual", "same as usual" to "better than usual". The sensi- (SD = 1.8). Depression, anxiety and incompetence all had tivity and specificity of the GHQ is estimated to be 81% significant and moderate correlations with somatization and 80%, respectively [40]. The alpha value for the total at T (all rho's ≥ .38, all ps ≤ 0.001). All three variables were GHQ-30 score in this study was .91. For depression the entered into a regression model but only anxiety and feel- alpha value was .83, for anxiety it was .91, and for feeling ing incompetent made a significant contribution. incompetent it was .71. Together these two risk factors accounted for 33% of the variance in somatization (F = 40.81, p ≤ .05). Page 4 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 Table 2: Final model. Negative affectivity and dissociation At T the mean score on dissociation was 6.1 (SD = 1.6) Beta Significance and the mean score on negative affectivity was 13.5 (SD = 3.8). Dissociation correlated moderately with somatiza- GHQ incompetence .27 ≥ .001 tion at T (rho = .40, p ≤ 0.01) while the correlation TSC negative affectivity .45 ≥ .001 between negative affectivity and somatization was high (rho = 0.62, p ≤ .001). The dissociation and the negative Note: Adjusted R square = .42 F = 57.44 affectivity subscales from the revised TSC were analyzed Final regression analysis with the revised TSC somatization subscale using linear regression. Alone, dissociation was signifi- as dependent variable and incompetence and negative affectivity as cant, but it failed to remain so, when negative affectivity independent variables. was introduced. Negative affectivity, however, was highly significant and explained 37% of the variance (F = 95.77, entirely to significantly predict somatization after negative p ≤ .005). affectivity was controlled for. Combination of significant risk factors Also contrary to previous findings, we found that arousal As a final step, all the significant measures were entered was the only PTSD symptom cluster to significantly pre- into a regression model together. When the risk factors dict somatization (although only until negative affectivity were entered together only negative affectivity reached sig- was controlled for). We did not examine numbing inde- nificance and feeling incompetent almost did (Table 1). pendently from the other avoidance symptoms, as was We tested the predictive value of PTSD severity one last done in the Escalona et al. study, so we do not know time by making a two-step regression analysis. At the first whether numbing alone would have been significant. In step we entered feelings of incompetence together with relation to the other study mentioned earlier, McFarlane HTQ total score. They were both highly significant (both et al. used the IES to measure PTSD and thus did not ps ≤ .001) and together predicted 36% of the symptom measure arousal. However, they did point out that the car- variance. However, when negative affectivity entered the diovascular, respiratory, and neurological symptoms that model at step two, HTQ total score completely lost signif- patients with PTSD often complain of are consistent with icance leaving only feelings of incompetence and negative physical symptoms of arousal. Following this line of affectivity as significant predictors of somatization (both thought it should not be surprising that the arousal cluster ps ≤ .001). Together these two measures accounted for in this study has proven to be a better predictor of soma- 42% of the total somatization variance (Table 2). tization than both intrusion and avoidance/numbing. However, even the arousal cluster of the HTQ did not remain significant when negative affectivity and feeling Discussion We did not in this sample find support for the hypothesis incompetent were controlled for. that dissociation and PTSD should be particularly related to somatization as suggested by Van der Kolk et al. [13]. There are a few possible explanations for why PTSD and Consistent with the finding by Salmon et al. [24], dissoci- dissociation failed to ultimately predict somatization in ation was a significant predictor of somatization but only this study. One possibility is that negative affectivity until negative affectivity was controlled for. Even more mediates the effect of PTSD on somatization. This hypoth- surprisingly, and contrary to the findings from the studies esis is supported by the fact that PTSD lost significance mentioned in this article, PTSD did not emerge as the when negative affectivity was controlled for. However, most important risk factor. In fact, PTSD severity failed another possibility is that the three concepts of dissocia- tion, posttraumatic stress, and somatization are only con- Table 1: significant risk factors. nected following more intrusive traumas such as childhood sexual abuse or perhaps adult rape or torture. Variable Beta Significance It is thus possible that both dissociation and PTSD would HTQ arousal .15 n.s. emerge as significant risk factors in such trauma samples GHQ anxiety .09 n.s. even after controlling for negative affectivity. This hypoth- GHQ incompetence .16 .053 esis is supported by the finding that exposure to natural TSC negative affectivity .32 .002 disasters (which has some features in common with the CSS feeling let down .06 n.s. industrial disaster that the sample in the present study had been subjected to) tends to be associated with PTSD but Note: Adjusted R square = .42 to be less related to somatization, dissociation, and affect F = 22.73 n.s.: not significant dysregulation than for example child abuse [13]. Last but New regression analysis with the revised TSC somatization subscale not least, dissociation and PTSD were measured at three as dependent variable and the previously significant measures as months in order to better establish a causal relationship independent variables. Page 5 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 between the two measures and somatization. However, if ing attempts. However, this relationship probably works dissociation and PTSD are not just risk factors but part of both ways, and somatization is very likely to further the somatization process, somatization should correlate decrease self-esteem and lead to feelings of incompetence. with dissociation and PTSD at T but not necessarily twelve months earlier. Therefore, the results do not show It is not as unexpected that we found negative affectivity whether dissociation and PTSD are involved in the proc- to be highly predictive of somatization, as this is in line ess of somatization but only that persistent psychological with studies on non-traumatised samples. However, it is dissociation and symptoms of posttraumatic stress meas- very interesting that we found negative affectivity to medi- ured three months after an industrial accident affecting a ate the effect of PTSD on somatization to such an extent residential area do not appear to explain the variance in that HTQ total score as well as the arousal sub-scale score somatization twelve months later above and beyond what failed to significantly predict somatization. As no other can be explained by negative affectivity and feeling study to our knowledge has controlled for negative affec- incompetent. tivity when examining somatization in a trauma sample, this important finding can neither be supported nor con- Depression and anxiety measured by the GHQ did not tradicted by other research. fare any better than PTSD and dissociation at predicting somatization. Whereas depression did not reach signifi- It has been proposed that trait negative affectivity has a cance even when first entering the analysis, anxiety was general non-specific relationship with symptom report- originally significant but failed to remain so after feelings ing, suggesting that people high on negative affectivity are of incompetence, arousal, negative affectivity, and feeling interoceptively hypervigilant and thus notice bodily let down were controlled for. This is probably due to neg- changes that go unnoticed in other people [31]. Another ative affectivity mediating the relationship between anxi- way through which negative affectivity may influence ety and somatization. As the definition of negative reporting of somatic symptoms is through recall bias affectivity is partly based on the tendency to experience caused by state-dependant recall [41]. Furthermore, neu- fear and anxiety it is not surprising that there should be roticism/negative affectivity may increase the actual prev- some overlap between the two concepts. It is intriguing alence of somatic symptoms through risk behaviours such that anxiety proved a better predictor of somatization as smoking, drinking, and using drugs [28]. Also, studies than did depression. As mentioned earlier, studies have have shown that people who score high on neuroticism generally found depression to be a better predictor of tend to have poor eating, sleeping, and exercise habits somatization than anxiety. This unexpected finding may [28]. be related to the use of an instrument that is not specifi- cally designed to measure the two variables. Negative affectivity is not uniquely associated with soma- tization but appears to be a general predictor of symp- In contrast to all these variables, feeling incompetent and tomatology. This is probably the reason why it appeared negative affectivity did significantly predict somatization to mediate the effect of both PTSD, dissociation, and anx- in this sample, together accounting for 42% of the iety on somatization in this study. Furthermore, negative somatoform symptom variance. As for feeling incompe- affectivity is related to somatization even in the absence of tent, it is quite interesting that a psychological measure a traumatic stressor. This study therefore suggests that that has been so little in the focus of research, actually even though somatization is particularly prevalent in trau- proved better at predicting somatization than did other- matised populations, the mechanisms behind traumatisa- wise well-established risk factors. What is really interest- tion do not appear to differ between traumatised and ing is that feeling incompetent was actually the only single general populations. (although it should be noted that a factor that remained significant when negative affectivity general population is not necessarily traumatised). Thus, was controlled for. This is despite the fact that such a even though PTSD and dissociation appear to be associ- measure of low self-esteem/self-efficacy could well be ated with degree of somatization in the aftermath of hypothesized to be mediated by negative affectivity as trauma, they do not surpass the importance of negative well as by PTSD. As the GHQ measure was taken at T affectivity as a non-specific risk factor of somatization. while somatization was measured at T , these results sug- gest that feeling incompetent increases the risk of somati- Limitations of the study zation, possibly by influencing the person's attempts to There are several limitations to this study. Most impor- cope with the traumatic event as well as with any somato- tantly, the use of combined measures was made necessary form symptoms. According to Murphy et al. [35], whether by the high number of variables examined, as more thor- a person engages in coping attempts depends on the ough testing of each single variable would have made the expectations he or she has concerning their success and questionnaire too time consuming for the participants. expecting failure may decrease the effect of any such cop- However, the TSC and the GHQ are designed to test sev- Page 6 of 8 (page number not for citation purposes) Clinical Practice and Epidemiology in Mental Health 2009, 5:1 http://www.cpementalhealth.com/content/5/1/1 eral psychological constructs combined and may not PTSD severity do not. More guided research focusing on measure variables such as dissociation and depression as variables such as self worth and self-efficacy will give more thoroughly as an instrument designed specifically to test detailed information on how it affects somatization. such variables. For example, it can be argued that the five items of the dissociation subscale used in this study is not Finally, this study examined a sample where all partici- quite enough to make a good estimate of dissociation in a pants had been subject to the same traumatic event. It traumatised sample. Furthermore, we assessed only per- should be studied whether the same risk factors apply to sistent psychological dissociation. Thus, neither peritrau- somatization after other trauma types – especially after matic nor somatoform dissociation will be revealed using more personal traumas such as torture, physical assault, or the revised TSC. Though persistent/pathological dissocia- rape where victims for example tend to dissociate more. tion has been shown to correlate with peritraumatic disso- ciation [43] the two measures may not predict Conclusion somatization equally well. Contrary to what other studies have found, depression did not significantly predict somatization in this study and Another limitation is that many of the houses in the dis- nor did anxiety and dissociation after negative affectivity aster area had to undergo major repairs and some had to was controlled for. Even more interesting, PTSD did not be rebuilt completely. This is a process that takes very long significantly predict somatization after controlling for time and for some people it was further delayed by prob- negative affectivity, suggesting that negative affectivity is a lems with insurance companies [36]. This means that the more important predictor of somatization even in trauma general level of stress can be expected to be quite high due samples than PTSD. In stead, negative affectivity and feel- to practical issues, relocation, and insecurity concerning ings of incompetence significantly predicted the degree of insurance outcomes. There is a risk that these stressors somatization, together accounting for 42% of the vari- may have influenced some of the different measures. For ance. This finding is to our knowledge unprecedented. example, negative affectivity is supposed to measure a per- sonality trait, but the negative affectivity scores may have Competing interests been increased by a high level of general stress in the sam- The authors declare that they have no competing interests. ple. Authors' contributions Last but not least, the sample consisted of people from the AE carried out the studies, performed the statistical analy- same small area of similar ethnicity, cultural background, ses, supervised the writing of the article and drafted the and middle class socioeconomic status. The results found manuscript. DMC performed the statistical analyses and here cannot automatically be extrapolated to populations wrote the article. 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