Objective
To explore patterns of experienced stress and stress reactions before the onset of illness in the life history of patients with severe somatoform disorders to identify predisposing stress-mechanisms.
Methods
A systematic, thematic analysis was conducted on data collected from 24 semi-structured individual life history interviews.
Results
Generally, patients had experienced high psychosocial stress during childhood/youth. However, there was considerable variability. Characteristic of all patients were narrations of how communication with significant adults about problems, concerns, and emotions related to stress were experienced to be difficult. The patients described how this involved conflicts stemming from perceived absent, insufficient, or dismissive communication during interactions with significant adults. We conceptualized this empirically based core theme as “emotional avoidance culture.” Further, three related subthemes were identified: Generally, patients 1.) experienced difficulties communicating problems, concerns, and related complex feelings in close social relations; 2.) adapted their emotional reactions and communication to an emotional avoidance culture, suppressing their needs, vulnerability and feelings of sadness and anger that were not recognized by significant adults; and 3.) disconnected their stress reaction awareness from stressful bodily sensations by using avoidant behaviors e.g. by being highly active.
Diseases that are associated with psychosomatic symptoms, like somatoform disorders (SD) and fibromyalgia (FM), are contested diseases with overlapping symptoms and uncertain etiology [1] and [2]. Evidence indicates that stress is part of the psychopathology, but the exact mechanisms between experienced stress and reactions to stress and the development of these psychosomatic diseases remain uncertain [1], [2], [3], [4], [5], [6] and [7]. Perceived stress is defined as “psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” [8]. Whether the stressor is perceived as a challenge or a threat will depend on former life experiences, stress appraisal, and coping resources [8], [9], [10] and [11]. Thus, memories, emotions, and coping resources play a crucial role in the stress experience and response [12] and [13]. The stress-concept is perceived as a bio-psychosocial phenomenon involving a subjective experience, a social context, and a physiological response.
The following familial risk factors in childhood have been identified associated with SD: somatization or organic disease of parents, psychopathology in close family members, dysfunctional family climate, traumatic experiences, and insecure attachment [14]. Another study finds an association between fibromyalgia and physical and sexual abuse [15]. Patients with fibromyalgia and/or SD more frequently report a poor emotional relationship with both parents, a lack of physical affection, and physical quarrels between parents [16]. Research examining the nature of these patients' early family environments also finds a significant association between: family dysfunction [17], trauma history, emotional abuse and neglect [18] and [19], insecure attachment styles [14], [19], [20] and [21] deriving from a dysfunctional milieu [22], negative affectivity [23] and [24], and alexithymia [23], [25], [26], [27] and [28]. Especially difficulty identifying feelings are associated with higher levels of psychological distress [27]. Affect dysregulation [29], [30] and [31], deficits in affective theory of mind [32], suppression of affect [30], [31] and [33], and decreased body and emotional awareness [34] and [35] are found associated with SD. Neuroendocrine dysfunctions are also found associated with fibromyalgia [36] and childhood trauma history [37]. Abnormal neural stress-processing is identified in relation to SD [33] and [38] suggesting some types of emotional and cognitive neglect.
Studies demonstrate that suffering from a contested psychosomatic illness can be stressful, related to identity crisis, and stigmatizing processes [39], [40], [41], [42], [43], [44], [45], [46] and [47]. These patients long for existential recognition of their illness [41], [42], [43], [44], [45], [46] and [47], needs, feelings, and vulnerability [48], and they experience insecure illness perceptions [41], [42], [43], [44] and [45] and difficulties communicating emotions of distress, which often leads to avoidant coping [48]. The aim of this paper is to gain new in-depth knowledge on the complex interaction of how patients experienced stress, reacted to and coped with stress before the onset of illness, which has not previously been investigated with qualitative methods, in order to identify new hypothesis on how stress can be a risk factor for developing psychosomatic related diseases. This study has explored all aspects that turned up to be significant in the patients' life narratives related to the research-target supplemented by questions echoing findings in the literature: What early experiences did these patients encounter, and how was the atmosphere in their childhood environments? What kinds of stressors, meaning traumatic events or difficult circumstances, had they experienced before falling ill? How did they react emotionally, somatically, and behaviorally to these stressors, and how did they cope to gain relief? How did they experience their interpersonal interactions and attachments to significant others including parents, teachers, friends and intimate partners? How did they talk about stressful experiences and related emotions of distress in social interactions, and what were their experiences of being socially supported?
