Professional Documents
Culture Documents
Psihosomatizacija
Psihosomatizacija
Psihosomatizacija
Somatizacijski poremećaj je poremećaj u kojem se psihički problemi i emocionalni konflikti izražavaju tjelesnim
simptomima, a somatizacija je psihološki mehanizam u kojem se psihički problemi i emocionalni konflikti manifestiraju
tjelesnim simptomima za koje se ne nalazi organska podloga. Može se javiti kao zasebni ili komorbidni poremećaj,
osobito s poremećajima raspoloženja, anksioznim poremećajima, poremećajima ličnosti (najčešće histrionski poremećaj
ličnosti i opsesivno-kompulzivni poremećaj ličnosti). Ovakve osobe primarno se javljaju u ambulante opće medicine
ili tjelesne ambulante i tek kasnije i na psihijatrijska liječenja. Liječenje osoba s tzv. somatoformnim poremećajima je
kompleksno, vrlo dugo i zahtjevno te je potrebna cijela lepeza psihijatrijskih vještina, često bez pozitivnih rezultata.
U ovom radu prikazana je pacijentica kod koje je traumatska i konfliktna situacija na poslu doživljena kao narcistička
povreda koja je dovela do razvoja dramatične kliničke slike u oblku somatizacija i somatizacijskog poremećaja kod
osobe s histronskim poremećajem ličnosti. Nemogućnost suočavanja s povredom selfa kod histrionskog poremećaja
ličnosti može dovesti do somatizacije kao načinom rješavanja problema. Prigodom liječenja je važno identificirati
točan uzrok, tj. okidač (engl. trigger) koji je doveo do nastanka poremećaja te suočiti pacijenta s psihološkom i
emocionalnom etiologijom tegoba, što uvelike doprinosi boljem terapijskom ishodu. Važnost pravovremenog
prepoznavanja somatizacija je između ostaloga nužna i zbog izbjegavanja nepotrebnih tjelesnih dijagnostičkih
postupaka, kao i zbog socijalne i radne disfunkcionalnosti takvih osoba.
/ Somatization disorder is characterized by a tendency of a person to communicate psychological distress and emotional
conflicts through physical symptoms, while somatization is a psychological mechanism manifesting psychological distress
and emotional conflicts as physical symptoms that lack an organic basis. It can develop as a single disorder or a mental
disorder comorbid with other disorders, especially co-occurring with mood disorders, anxiety disorders, and personality
disorders (most commonly, histrionic and obsessive-compulsive personality disorders). In most cases, people suffering
from such disorders seek help from general practitioners or at healthcare facilities specialized for physical disorders. It is
only after this that they seek psychiatric assistance.
The treatment of people suffering from so-called somatoform disorders is complex, time-consuming and demanding and
it requires a broad spectrum of psychiatric skills. However, it rarely yields positive outcomes.
This research paper focuses on a case study of a patient with histrionic behaviour who experienced a conflict situation at
work as a narcissistic injury. The narcissistic injury triggered the development of a dramatic clinical picture in the form of
somatization and, consequently, the development of the somatization disorder.
The inability of a person with a histrionic personality disorder to confront an injury of self can trigger somatization as a
defence mechanism. The treatment requires careful identification of the root cause, the so-called trigger that initiated
the development of the disorder, and the confrontation of a patient with the psychological and emotional etiology of
his/her symptoms. Such an approach has a profound impact on a more positive outcome of the therapy. However, timely
detection of somatization is important, among other things, to avoid unnecessary physical diagnostic procedures and to
enable the normal performance of social and occupational roles of a patient.
UVOD INTRODUCTION
Somatizacija je psihološki mehanizam u ko- Somatization is a psychological mechanism of ex-
jem se psihički problemi i emocionalni kon- pressing somatic distress and symptoms and at-
flikti izražavaju tjelesnim simptomima i ma- tributing them to a wide spectrum of polymorphic
nifestira se cijelim nizom polimorfnih tegoba health conditions that lack an organic basis. Fur-
za koje se ne nalazi organska podloga. Soma- thermore, somatization is a tendency of a person
to experience and communicate somatic distress
tizacija je tendencija osobe da komunicira
and to seek medical assistance to alleviate it. Con-
psihološki distres somatskim simptomima
sequently, somatoform disorders are usually first
i traži za njih medicinsku pomoć, pa se so-
observed at non-psychiatric medical facilities (by
matoformni poremećaji tipično prvo vide u
general practitioners and various medical profes-
nepsihijatrijskom okruženju (liječnici opće sionals specialized in physical illnesses) (1). Con-
medicine i razni specijalisti tjelesne medicine) version disorder is a specific form of somatization
(1). Konverzivni poremećaj je specifični oblik commonly characterized by functional neurolog-
somatizacije u kojem su prisutni funkcional- ical symptoms. If symptoms manifest as a part of
ni neurološki simptomi i ako se manifestiraju the multisystem somatoform syndrome, somati-
kao dio multisustavnog somatoformnog sin- zation disorder is the primary diagnosis (2).
droma primarna dijagnoza je somatizacijski The history of somatization is related to the his-
poremećaj (2). tory of hysteria, which was considered to be a fe-
Povijest somatizacija povezana je s povijesti male disease exclusively until the 1950s (3).
histerije za koju se smatralo da ekskluzivno The Diagnostic and Statistical Manual of Mental
zahvaća žene, a njezino poimanje se je počelo Disorders – IV (DSM-IV) classification (4), as well
mijenjati nakon 1950. godine (3). as the International Statistical Classification of
Diseases and Related Health Problems – 10 (ICD-
Somatoformni poremećaji bili su klasificirani u
10) (5), included somatoform disorder. However,
DSM-IV klasifikaciji (4), kao i u MKB-10 klasi-
the Diagnostic and Statistical Manual of Mental
fikaciji (5), a u DSM-5 klasifikaciji ova skupina
Disorders – V (DSM-V) classification classifies so-
poremećaja je postala poremećaj sa somatskim matoform disorder as a disorder characterized by
simptomima (6), dok se poremećaji s organski somatic symptoms (6). Furthermore, this classi-
neobjašnjenim simptomima dijagnosticiraju fication classifies disorders with symptoms lack-
kao konverzivni poremećaj (poremećaj s funk- ing an organic basis as a conversion disorder (a
cionalnim neurološkim simptomima) i više disorder characterized by functional neurological
nema somatizacijskog poremećaja. U MKB-10 symptoms) and omits somatization disorder. The
Konverzivni poremećaj ima obično iznenadni Commonly, conversion disorder has a sudden on-
početak, kratkog je trajanja za razliku od so- set and is of a shorter duration, while so-called
matoformnih poremećaja koji imaju kroničan somatoform disorders are chronic in nature.
The main characteristic of conversion disorder
tijek. Glavno obilježje konverzivnog poreme-
is a presence of symptoms or a lack of voluntary
ćaja je prisutnost simptoma ili deficita voljne,
motor or sensory control, usually indicative of
motoričke ili osjetilne funkcije koji upućuju
a neurological illness or disorder (e.g. paraly-
na neku neurološku bolest ili neki drugi po-
sis, contracture, hyperkinesis including various
remećaj (pareze, paralize, kontrakture, hiper- forms of tremor affecting the head, extremities
kinezije u obliku tremora glave, ekstremiteta and the whole body, various forms of tics, as well
i cijeloga tijela, različiti tikovi kao i poreme- as speech disorders, namely stuttering, aphasia
ćaji govora kao mucanje, afazija i mutizam). and mutism). Psychological factors are identified
Uzrokovan je psihološkim čimbenicima jer je as underlying factors since it has been observed
zamijećeno da pojavi ili pogoršanju simptoma that a conflict or other psychological stressor
ili deficita prethodi konflikt ili drugi stresor. usually precedes the onset or the deterioration
Somatizacijski poremećaj je jaki psihijatrijski of symptoms. Somatization disorder is a serious
poremećaj koji se odlikuje mnogim recidivira- psychiatric condition characterized by numerous
jućim značajnim tjelesnim tegobama, a simp- significant recurring physical symptoms affecting
any part or system of the body or several organ
tomi mogu uključivati jedan ili više tjelesnih
systems or functions. The symptoms can be car-
sustava ili funkcija, kao što su kardiopulmo-
diopulmonary, gastrointestinal, genitourinary,
nalni, gastrointestinalni, genitourinarni, mus
musculoskeletal or neurological and are usually
kuloskeletalni, neurološki simptomi uz umor i
accompanied by fatigue and pain (7).
bol (7).
Somatization disorder is often comorbid with
Kod somatizacijskog poremećaja prisutan je other psychiatric disorders, especially mood dis-
komorbiditet s drugim psihijatrijskim poreme- orders, anxiety disorders, or personality disorders
ćajima, osobito s poremećajima raspoloženja, (most commonly histrionic and obsessive-com-
anksioznim poremećajima, poremećajima lič- pulsive personality disorders) (8).
nosti (najčešće histrionski poremećaj ličnosti i
The etiology of the somatization disorder ac-
opsesivno-kompulzivni poremećaj ličnosti) (8). counts for a wide diversity and broad spectrum of
Etiologija somatizacijskog poremećaja je vrlo clinical manifestations suggesting its multifacto-
raznolika jer postoje i različite kliničke mani- rial etiology. Predisposing factors include genetic,
festacije što i ukazuje na multifaktorsku etio- psychodynamic, neuropsychological-neurophys-
iological-psychophysiological, and personality
logiju. Predisponirajući čimbenici mogu biti:
traits (e.g. neuroticism, alexithymia, negative
genetski, psihodinamski, neuropsihološko-ne-
affectivity, introspection, etc.), developmen-
urofiziološko-psihofiziološki, crte ličnosti (ne-
tal-learning and sociocultural factors (9). While
uroticizam, aleksitimija, negativni afektivitet,
dominant etiological factors can be prevalent in
introspektivnost, itd.), razvojno učenje i socio one patient, they can be minor in another patient.
kulturni (9). Dominantni etiološki čimbenici
In the psychodynamic approach, traditional psy-
mogu kod jednog pacijenta biti predominiraju-
choanalysis explains the conversion disorder as a
ći, a kod drugog minorni.
symbolic representation of subconscious conflicts
U psihodinamskim teorijama klasično psiho- (violent and sexual in nature). In the contempo-
analitičko razumijevanje konverzivnog pore- rary Western world, somatic symptoms explained
Postavljene su dijagnoze somatizacijskog pore- She does not hesitate to show her hostility to-
wards men openly, to say they cannot be trusted.
mećaja komorbidnog s histroničkim poremeća-
However, she starts a relationship with a patient
jem ličnosti.
in the same ward. Her relationship with her son
Terapijski ciljevi su bili ograničeni i usmjereni is emotionally cold. He does not come to the hos-
na razvoj mogućnosti introspekcije, stjecanje pital to visit her. At the same time, while at the
uvida o utjecaju histrionskog ponašanja na hospital, she demands a maximum involvement
okolinu, učenje toleriranja negativnih emocija, from her sister in her treatment.
postavljanje jasnih granica u odnosima i reduk- She is diagnosed with a somatization disorder
ciju ovisničkog ponašanja. Psihoterapijsko lije- comorbid with a histrionic personality disorder.
čenje bilo je moguće započeti tek nakon reduk-
The treatment goals are limited to and focused on
cije početne anksioznosti, histrionskog načina
the development of her introspection potential,
reagiranja i somatizacija. Bolesnica postupno i as well as on raising awareness about the histrion-
samo djelomično stječe uvid u psihološku etio- ic behaviour’s impact on the environment. In addi-
logiju svojih smetnji u smislu psihološke nad- tion, the goal is to learn skills to tolerate negative
gradnje. Prihvaća konfliktnu situaciju sa šefom emotions, to learn to create healthy boundaries in
kao jedan od mogućih uzroka za nastanak nje- relationships and to reduce addictive behaviours.
zinih tegoba. Nakon otpusta nije došla na do- The psychiatric treatment starts after reducing the
emocionalnom etiologijom tegoba. Postoje ra- In the case of the patient, identified therapeutic
zličite terapijske mogućnosti, iako često s vrlo goals during hospitalization were limited due to
ograničenim rezultatima. Vrlo često je potreb- prevalent heightened anxiety.
na psihofarmakološka terapija s obzirom na It is common for untreated patients to feel bitter,
visoki stupanj anksioznosti, ali i komorbidnih angry, distrustful and not be capable of running
anksioznih i depresivnih poremećaja (pacijen- everyday errands. Where treatment is concerned,
tica je dobivala anksiolitik i antidepresiv) (1,8). it is important to identify the accurate cause – the
Što se tiče psihoterapijskog liječenja ono može trigger that caused the problem in the first place.
biti: etiološko s psihodinamskim (17) i integra- Furthermore, it is of greatest importance for pa-
tivno-psihoterapijskim pristupom (24), koji su tients to be confronted with the psychological and
usmjereni na rješavanje emocionalnih konfli- emotional etiology of their problems. A number of
kata u podlozi somatizacije ili simptomatsko, therapeutic approaches are available, but the re-
sults attained are often limited. Most commonly,
najčešće kognitivno-bihevioralni pristup (25),
therapeutic approaches include psychopharma-
koji je usmjeren na identificiranje negativnih
cological therapy to decrease heightened anxiety,
misli, rad na impulzivnom ponašanju, učenje
but also to treat comorbid anxiety and depressive
vještina rješavanja problema. Dodatne terapij-
disorders (the patient was prescribed anxiolytics
ske mogućnosti su uključene u grupni psihote- and antidepressants) (1,8). Where psychothera-
rapijski rad (26,27). peutic treatment is concerned, there are various
Teškoće u verbaliziranju emocija, razlikovanju approaches: etiological combined with psychody-
između tjelesnih senzacija i različitih emotiv- namic (17) and integrative-psychotherapeutic ap-
nih stanja, zbunjenost i frustracija kada se proach (24), aimed at solving underlying emotional
conflicts that trigger somatizations. Another pos-
pokušava razgovarati o emocionalnom doživ-
sibility is a symptomatic cognitive-behavioural ap-
ljavanju zbog aleksitimičnih karakteristika
proach (25) aimed at identifying negative thoughts,
(28,29) čine komunikaciju s ovim pacijentima
modifying impulsive behavioural patterns, learning
otežanom i napornom. Odsustvo simboličkog
problem-solving skills. Additionally, a group-work
razmišljanja i siromaštvo fantazija izraženi su
approach is also recommended (26,27).
do te mjere da kod terapeuta kontratransferno
The alexithymic traits (28,29) of somatising pa-
uzrokuju osjećaj praznine i dosade.
tients, namely difficulty in articulating and identi-
S obzirom na česte somatizacije ove osobe ne- fying feelings and distinguishing between feelings
rijetko prolaze niz nepotrebnih medicinskih and the bodily sensations, as well as confusion and
pretraga uzrokujući frustraciju liječnika i me- frustration that arise in conversations focused on
dicinskog osoblja. U većini slučajeva psihoa- their emotional experience make communication
nalitički orijentirana psihoterapija ne dovodi with patients difficult and demanding. A lack of
do poboljšanja tako da se kod ovih pacijenata symbolic reasoning and restricted imagination are
mogu, pored suportivne psihoterapije, kom- so pronounced that, countertransferentially, the
binirano koristiti različiti terapijski postupci therapist may begin to feel emptiness and boredom.
poput kognitivno-bihevioralnih postupaka, As a consequence of frequent somatizations, so-
metoda primijenjene psihofiziologije (engl. matising patients commonly subject themselves
LITERATURA / REFERENCES
1. Hurwitz TA. Somatization and conversion disorder. Can J Psychiatry 2004; 49(3): 172-8.
2. Lazare A. Current concepts in psychiatry. Conversion symptoms. New Engl J Med 1981; 305(13): 745-8.
3. Wool AC, Barsky JA. Do women somatize more than men? Gender differences in somatization. Psychosomatics 1994;
35(5): 445-52.
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington,
DC: American Psychiatric Association, 2000.
5. World Health Organization. ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic
Guidelines. Geneva: World Health Organization, 1992.
6. Jukić V, Arbanas G. (ur.) Američka psihijatrijska udruga. Dijagnostički i statistički priručnik za duševne poremećaje - peto
izdanje (DSM-V). Jastrebarsko: Naklada Slap, 2014.
7. Servan-Schreiber D, Kolb NR, Tabas G. The somatizing patients: part I. Practical diagnosis. Am Fam Physician. 2000; 61(4):
1073-8.
8. Somatization disorder. U: Encyclopedia of Mental Disorders. Preuzeto 10. svibnja 2018. http://www.minddisorders.com/
Py-Z/Somatization-disorder.html
9. Tony I, Duckworth PM, Adams EH. Somatoform and factitious disorders. U: Sutker BP, Adams EH, (ur.) Comprehensive
Handbook of Psychopathology. New York: Kluwer Academic/Plenum Publishers, 2001, str. 211-258.
10. Alliance of Psychoanalytic Organizations. Psychodynamic Diagnostic Manual (PDM). Silver Spring, MD: Alliance of Psyc-
hoanalytic Organizations, 2006.
11. Lipowski ZJ. Somatization: The concept and its clinical application. Am J Psychiatry 1988; 145(11): 1358-68.