Psychiatry and Clinical Neurosciences 2009; 63: 508515

doi:10.1111/j.1440-1819.2009.01994.x

Regular Article

Body image and self-esteem in somatizing patients

Ozen O. Sertoz,

pcn_1994

508..515

MD,1* Ozge Doganavsargil, MD2 and Hayriye Elbi, MD1 1 Department of Psychiatry, School of Medicine, Division of Consultation Liaison Psychiatry, Ege University, Izmir and 2 Department of Psychiatry, School of Medicine, Akdeniz University, Antalya, Turkey

Aim: The aim of the present study was to determine dissatisfaction with body appearance and bodily functions and to assess self-esteem in somatizing patients. Methods: Body image and self-esteem were investigated in 128 women; 34 of those had diagnosed somatoform disorders, 50 were breast cancer patients with total mastectomy surgery alone, and 44 were healthy subjects. Body image and self-esteem were assessed using the Body Cathexis Scale and Rosenberg Self-Esteem Scale. Results: The two clinical groups did not differ from one another (z = -1.832, P = 0.067), but differed from healthy controls in terms of body image (somatizing patients vs healthy controls, z = -3.628, P < 0.001; total mastectomy patients vs healthy controls, z = -3.172, P = 0.002). They also did not differ signicantly in terms of self-esteem (z = -0.936, P = 0.349) when depressive symptoms were

controlled. No statistically signicant difference was observed between total mastectomy patients and healthy controls in terms of self-esteem (z = -1.727, P = 0.084). The lower levels of self-esteem in somatizing patients were largely mediated by depressive symptoms. Depressed and non-depressed somatizing patients differed signicantly from healthy controls with respect to their self-esteem and body image.

Conclusions: Somatizing patients who were dissatised with their bodily functions and appearance had lower levels of self-esteem and high comorbidity of depression. In clinical practice it is suggested that clinicians should take into account psychiatric comorbidity, self-esteem, and body image in somatizing patients when planning treatment approaches.
Key words: breast cancer, body image, healthy controls, self-esteem, somatization.

ODY IMAGE REFERS to ones feelings, perceptions, and attitudes towards ones physical self, appearance, overall wholeness, functionality, and ability to relate to others. Body image is also dened as part of an individuals self-worth.1 The literature suggests a strong link between body image and selfesteem,2,3 because one of the important domains of self-esteem is body esteem, which is related to feelings about ones general appearance or attributions concerning others evaluation of appearance and weight.4 Disturbances in body image generally occur

*Correspondence: Ozen Onen Sertoz, MD, Ege Universitesi Tip Fakultesi Psikiyatri Anabilim Dali 35100 Izmir, Turkey. Email: onensertoz@gmail.com Received 26 August 2008; revised 20 March 2009; accepted 28 March 2009.

when there is a discrepancy between the way one has formerly perceived himself/herself and how he/she now perceives himself/herself after a physical or a psychiatric illness. In the literature it has been found that breast cancer and head and neck cancers are associated negatively with body image.58 As well as cancers, rheumatic diseases and obesity were some of the diseases that were associated with negative body image.9,10 In addition, numerous studies have examined body image and self-esteem in psychiatric disorders. Mendelson et al. have reported that women with eating disorders rate themselves signicantly lower on body esteem and self-esteem as compared to healthy subjects; furthermore, they found a positive relationship between body esteem and selfesteem among women with eating disorders but not among healthy subjects.2

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Beyond the literature knowledge concerning body image and self-esteem in different medical and psychiatric diseases, there is a lack of data about body image disturbances and self-esteem in somatizing patients. There is much more evidence that the frequency of somatoform disorders is similar across cultures, but somatic expression of distress is a universal phenomenon,11 its manifestations can vary across cultures. In less-developed countries, somatic complaint might be an indicator of unmet psychiatric need, while the same symptom in more developed countries might be a symbol of psychosocial distress.12 The question of why these patients somatize is still an important one that needs to be answered. Physical symptoms in somatizing patients have a somatosensory amplication, which refers to the tendency to experience somatic sensations as intense, noxious, or disturbing. In addition to somatosensory amplication theory, the social stigma associated with mental illness may be an important determinant of the somatic expression of emotional distress, because in many contexts physical illness is more socially acceptable than psychiatric problems.13 Somatization of any degree is associated with the female gender, as well as lower educational level, lower household income, and living in a rural area.14,15 Medically unexplained somatic symptoms are widely prevalent in primary care settings and general hospitals, and they are associated with increased health-care utilization in many countries as well as in Turkey. The management of somatoform disorders is very difcult, and the physical symptoms tend to become chronic and refractory to usual treatments. The literature ndings emphasizing negative body image and self-esteem in a variety of psychiatric disorders led us to suggest a hypothesis that somatizing patients might have some problems not only with their bodily functions but with their body appearance as well. Therefore, alternative therapies other than pharmacotherapy and cognitive behavioral therapy, such as body-oriented approaches in psychotherapy, regular exercise, or aerobic dance therapy, were also shown to have positive impact on body image16,17 and could serve as an alternative or a complementary treatment option for somatizing patients. We decided to test this hypothesis by comparing somatizing patients with breast cancer patients and healthy subjects in order to assess body appearance and bodily functions. To our knowledge there is no study addressing body image concerns and self-esteem in somatizing patients in Turkey.

METHODS
This was a cross-sectional, casecontrol study.

Subjects
Women within the age range of 1855 years were recruited for the study. The following constituted the three groups of the study: (i) women who had a diagnosis of somatoform disorder; (ii) women who had been diagnosed with breast cancer, had total mastectomy surgery alone, and currently were considered as disease free, and who had not received any cancer therapy within the past 1 year other than hormonotherapy; and (iii) age-matched healthy control subjects. To control for the negative effect of menopause, however, on body image and self-esteem as confounding factors, in all three groups we included only women who were still menstruating. There is a preconception that somatizing patients have low socioeconomic status14 but, to avoid any bias, we matched the healthy subjects to the test subjects only by age, not social status. Because comorbid depression and anxiety disorders were frequently seen among patients with somatoform disorders,18,19 we did not exclude these psychiatric comorbidities. In the present study clinically signicant suicidality was the exclusion criterion.

Somatizing patients
The somatizing patients consisted of 34 women (mean age 41.76 8.42 years). Patients who were referred to Department of Psychiatry, School of Medicine, in the Consultation Liaison Division of Ege University, Izmir, Turkey with an initial diagnosis of somatization disorder between March 2002 and July 2002 were recruited for the study. A total of 104 patients were referred to the department; among all, 21 were male, 42 subjects were postmenopausal women, and seven were psychotic, thus all were excluded from the study. After being interviewed using the Turkish version of the Structured Clinical Interview for DSM-IV (SCID-I),20,21 13 patients were diagnosed with somatization disorder, 19 were diagnosed as having undifferentiated somatoform disorder, and two had a diagnosis of hypochondriasis. Of these 34 patients, 19 had a comorbid diagnosis of major depressive disorder as assessed on SCID-I. In

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summary, 70 patients were excluded because they did not t the inclusion criteria, and the remaining 34 patients were included.

Procedure
After all study subjects gave their written informed consent, they completed the study forms. Two psychiatrists administered the SCID-I to all study subjects and also evaluated them for cognitive ability.

Total mastectomy patients

Breast cancer remains the leading malignancy among women, and it appears to be the most studied medical condition for its psychological and psychosocial aspects. Furthermore, body image is also widely studied in breast cancer research, and the established data suggesting the negative impact of breast cancer on body image provide a new question for the exploration of body image issues in somatization.5,7,22,23 It is possible that patients with severe disgurement, such as amputation, or oral cancer patients with ap reconstruction, could have been chosen as comparison groups in the present study. But although the disgurement related to total mastectomy is minimal and could be mimicked by external breast prosthesis, as compared to severe disgurement resulting from other causes, the meaning of mastectomy is very important for the patient because it refers to her femininity and sexuality. Therefore the disgurement might be minimal in total mastectomy patients but the attributions are strong. We therefore determined the breast cancer group to be closer in comparison to somatizing patients than amputees or patients with other types of cancer. Breast cancer patients with total mastectomy surgery alone were recruited to the study between September 2001 and July 2002. During that period 483 subjects were contacted on their control visits at the General Surgery Department, School of Medicine, Ege University, Izmir, Turkey. Among them, 50 cancer patients (mean age 40.58 4.09 years) fullled the inclusion criteria and were enrolled. The length of time since total mastectomy was 2.98 1.15 years.

Measures
Body Cathexis Scale The Secord and Jourard Body Cathexis Scale (BCS) was used in the present study.24 The BCS is a 40-item, self-report instrument that assesses the degree of satisfaction with the functions and appearance of ones body. The patient is asked to rate satisfaction with each body part on a 5-point Likert-type scale, from 1 (strongly like) to 5 (strongly dislike). The scale includes 40 items, with the minimum score being 40 and the maximum score being 200. An overall score was obtained by summing the ratings and a mean score was calculated, with higher scores representing higher body dissatisfaction. In Turkey the validity and reliability studies of this scale were conducted by Hovardaoglu, and the internal consistency was found to be 0.88.25 Rosenberg Self-Esteem Scale The Rosenberg Self-Esteem Scale (RSES) scale consists of 10 items designed to measure ones overall selfesteem. Items are scored on a scale spanning strongly agree to strongly disagree. The self-esteem score was calculated using Guttman scaling. Self-esteem is considered to be high when the total score of the rst 10 items is 01, moderate if the total score is 24, and low if the total score is 56. Higher scores indicate lower self-esteem. The validity and reliability has previously been established for Turkish subjects.26 In that study the correlation coefcient between the interview scores and the score of the self-esteem scale was 0.71. Structured Clinical Interview for DSM-IV The SCID-I is a semi-structured diagnostic interview designed to assist clinicians, researchers, and trainees in making reliable DSM-IV psychiatric diagnoses.20 Statistical analysis Descriptive statistics were used to examine the characteristics of the samples. The c2 test was used to

Healthy control subjects

Age-matched control subjects were recruited from the neighbors of the somatizing and total mastectomy patients and from the Ege University Hospital staff (nurses and civil servants) who had no known psychiatric or medical illnesses and who had regular menstruations during the course of the study. The healthy control group consisted of 44 women, mean age 39.8 5.12 years.

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compare categorical measures. Age and educational level were compared with ANOVA. The three groups were compared on covariance analysis with respect to body image and self-esteem. Pairwise comparisons were made using MannWhitney U-test. Pearsons correlation coefcient was used to examine the relationship between body image and self-esteem. Statistical analysis was conducted using SPSS version 11 (SPSS, Chicago, IL, USA), with P < 0.05 accepted as statistically meaningful.

RESULTS
Sociodemographic characteristics
Age and income level were similar between the three groups. Somatizing patients were less collegeeducated compared with total mastectomy and healthy control groups (Table 1).

nicant differences between the three groups with respect to body image and self-esteem (Table 2). The self-esteem and body image scores had abnormal distribution in each sample, therefore we did pairwise comparisons using the MannWhitney U-test. The somatizing patients had the lowest self-esteem among the three groups. Statistically signicant differences in self-esteem were found between somatizing patients and total mastectomy patients and between somatizing patients and healthy controls. No statistically signicant difference was observed between total mastectomy patients and healthy controls (Table 2). The somatizing patients had the highest score on the body image scale. Somatizing patients did not differ signicantly from total mastectomy patients with respect to body image, but both somatizing and total mastectomy patients differed signicantly from healthy controls (Table 2).

Comparison of body image and self-esteem

Because the study groups were signicantly different according to educational and occupational status, we performed comparison of body image and selfesteem using covariance analysis. Mean education (years) and occupational status were entered as covariates in the test. The test indicated statistically sig-

Comparison of depressed and non-depressed somatizing patients with respect to body image and self-esteem
As described in the previous section, 19 of 34 somatizing patients had comorbid major depression. Although self-esteem of non-depressed somatizing patients (1.53 1.76) was higher than of depressed patients (2.31 1.45) and the difference was statistically signicant (z = -2.214, P = 0.027), there was

Table 1. Subject characteristics

Total mastectomy patients n = 50 Mean Age (years) Educational level (year) Income level Low Intermediate Upper intermediate High Occupational Status Housewife Civil servant Retired

Somatizing patients n = 34 Mean 41.76 7.47 n 0 8 17 9 25 2 7 SD 8.42 3.89 % 0 23.5 50 26.5 73.5 5.9 20.6

Healthy controls n = 44 Mean 39.8 11 n 3 7 17 17 13 28 3 SD 5.12 4.45 % 6.8 15.9 38.6 38.6 29.5 63.6 6.8 Signicance F = 1.101 P = 0.336 F = 7.781 P < 0.001 P = 0.06

SD 4.09 4.09 % 12 26 20 42 50 36 14

40.58 10.48 n 6 13 10 21 25 18 7

P < 0.001

ANOVA;

c test.

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Table 2. Self-esteem and body image scores

Total mastectomy patients n = 50 Somatizing patients n = 34 Healthy controls n = 44

Statistical analysis MannWhitney U-test z = -2.757 P = 0.006 z = -4.352 P < 0.001 z = -1.727 P = 0.084 z = -1.832 P = 0.067 z = -3.628 P < 0.001 z = -3.172 P = 0.002

Mean RSES 1.2

SD 1.52

Mean 1.97

SD 1.62

Mean 0.61

SD 0.78

Covariance P = 0.005 d.f. = 2.123 F = 5.46

BCS

2.34

0.45

2.62

0.79

2.01

0.396

P < 0.001 d.f. = 2.123 F = 12.57

Pairwise comparisons between somatizing patients and total mastectomy patients, between somatizing patients and healthy controls and between total mastectomy patients and healthy controls respectively for self-esteem. Pairwise comparisons between somatizing patients and total mastectomy patients, between somatizing patients and healthy controls and between total mastectomy patients and healthy controls respectively for body image. BCS, Body Cathexis Scale; RSES, Rosenberg Self-Esteem Scale.

no statistically signicant difference with respect to body image (body image of non-depressed somatizing patients, 2.58 0.84; depressed somatizing patients, 2.65 0.77; z = -0.347, P = 0.729). We compared non-depressed somatizing patients with total mastectomy patients and healthy controls in terms of self-esteem and body image and found no statistically signicant differences with respect to self-esteem (z = -0.936, P = 0.349) or body image (z = -0.756, P = 0.45) between non-depressed somatizing patients and total mastectomy patients; but there were still statistically signicant differences between non-depressed somatizing patients and healthy controls with respect to self-esteem and body image (z = -2.207, P = 0.027 and z = -2.272, P = 0.023).

and self-esteem in healthy controls (r = 0.203, P = 0.185).

DISCUSSION
The present results conrmed that somatizing patients were dissatised with both their bodily functions and appearance. In other words, somatizing patients had an impaired body image at least as much as total mastectomy patients did. In addition, both somatizing and total mastectomy patients did not differ signicantly from one another based on self-esteem when depression was controlled. The somatizing patients did differ signicantly, however, in terms of self-esteem when compared with healthy subjects. The present ndings indicated, as we anticipated, that somatizing patients were less college educated than total mastectomy patients and healthy controls. Therefore, our study demonstrated consistent results with previous ndings.14,15 In the present study the lower levels of self-esteem in somatizing patients were signicantly related with depression. This nding was consistent with that reported by Phillips et al., in which the relationship

Relationship between body image and self-esteem

We found signicant positive correlations between self-esteem and body image among breast cancer patients (r = 0.318, P = 0.024) and non-depressed somatizing patients (r = 0.628, P = 0.012). No meaningfully associations were found between body image

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between body dysmorphic disorder severity and selfesteem was found to be largely mediated by depressive symptoms.27 In addition to the similar self-esteem prole, somatizing patients and total mastectomy patients differed from healthy controls, but not from each other, with respect to the greater severity of their body image symptoms. Contrary to self-esteem, however, body image was not affected by depressive symptoms. We found that >50% of somatizing patients had comorbid depression. This nding was consistent with the related literature.18 Low self-esteem is one of the symptoms of depression, and low self-esteem and depression are found to be strongly correlated in many studies.28 Nonetheless, there is lack of knowledge about their prospective effects on each other to determine whether low self-esteem serves as a risk factor for depression, or whether low self-esteem is an outcome not a cause of depression. These hypotheses were tested in a recent study, and it was found that low self-esteem predicted subsequent levels of depression, but depression did not predict subsequent levels of self-esteem.29 In the present study we found that somatizing patients had similar levels of self-esteem as compared to total mastectomy patients, but they had lower levels of self-esteem as compared to healthy controls when depression was controlled. Therefore, we can suggest that not only is self-esteem low among somatizing patients, but it diminishes even more when they are depressed. As we discussed above, the two clinical patient groups did not differ from each other with respect to body image and self-esteem. Somatizing patients body image was at least as impaired as the total mastectomy patients body image. The latter is perhaps the most important nding of the present study. In breast cancer cases, impaired body image often results from radical treatments on the body itself. In addition, breast cancer patients have to cope with the reality of an organ loss, which is in itself closely associated with self-esteem, sexuality, as well as femininity.30,31 External breast prostheses, which are frequently worn by total mastectomy patients, may help them cope with breast loss, but impaired body image is not repaired with external breast prostheses.32 In contrast, in somatizing patients, although there is no real loss of an organ or no disturbed body part or organ function, the patient complains about impaired body functions, but they do not complain about the appearance of their body or body parts. In this respect, we believe that somatizing patients

perception of poorer body image (similar to total mastectomy patients) is a very important nding and may indicate dissatisfaction with their body appearance. In the present study we found a positive association between body image and self-esteem in total mastectomy and in non-depressed somatizing patients, but we failed to nd a similar association both in depressed somatizing patients and in healthy controls. Therefore, in non-depressed somatizing and total mastectomy patients this nding was consistent with studies reporting a correlation between poor body image and poor self-esteem.2,3,33 The reason we could not nd a similar relationship between body image and self-esteem in depressed somatizing patients may be due to the effect of depression. As a second explanation, these results could be totally random due to the limited number of participants. Body image refers to the perception of ones body: an attitude about ones physical self, appearance, overall wholeness, functionality, and ability to relate to others. Conceptualization of body image through this perspective gives us some important clues about a persons inner world. First, early childhood trauma, social difculties, and emotional distress may lead to impairment in body image. Second, we suggest that the body dissatisfaction seen among somatizing patients may be considered as the body-related equivalent of psychopathological disturbances or symbolic bodily represented emotional distress. Third, lower educational level may also lead to impairment in body image as well as in the manifestation of somatization. There were some limitations to the present study. First, this was a cross-sectional, casecontrol study conducted within a small sample in only one institution. Thus, the results could not be generalized to the overall population of women. Second, we excluded male somatizers in order to form a unique sample. In the literature, it has been suggested that the relation between gender and somatization is complex and poorly understood. Although it has been a common/traditional belief that women somatize more than men, recent studies have produced inconsistent results.34,35 Therefore, the lack of male subjects in the current study may be a shortcoming that inuenced the ndings. Third, the current study was a casecontrol study, so conclusions relating to causality are not possible. The results suggest only an important relationship between body image, selfesteem, and somatization.

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Identifying body image and self-esteem concepts in somatizing patients can provide useful information for choosing appropriate psychological therapy. Based on a literature search, there is no exact knowledge on the differences in managing depressed or non-depressed somatizing patients. Only in a review article was this issue investigated, and the author of that article concluded that there are limited data in this area.36 But in recent studies it has been found that somatization increases disability, medical utilization, and costs independent of medical or psychiatric comorbidity.37,38 Therefore, much of the inuence that depressive and anxiety disorders exert on utilization is moderated through their effect on somatization. In line with these ndings, we suggest that comorbidity of depression and anxiety in somatization could increase the severity of somatization and reduce its response to treatment. Therefore, to manage somatization we need new therapy options or combined treatments other than pharmacotherapy. Consistent with this assumption, one of the body-oriented approaches in psychotherapy, bioenergetic analysis, assumes that important life experiences are retained not only in the psychic subconscious but also in the body, where they are expressed in respiration, posture, movement as well as experience and behavior.39 In a recent study this technique was shown to be effective in the treatment of Turkish immigrants with chronic somatoform disorders.16 In addition, cognitive behavioral therapy has been reported to be the best established treatment for a variety of somatoform disorders.40 Beyond these psychological treatments, regular exercise and aerobic dance therapy were shown to have positive impact on body image.17 Therefore in clinical practice we suggest that clinicians should take into account the comorbid psychiatric disorders as well as the self-esteem and body image concerns of somatizing patients when planning treatment approaches. In conclusion, we have demonstrated that somatizing patients have impaired body image and low self-esteem at least as much as total mastectomy patients do; also, they have poorer body image and self-esteem compared with healthy controls. In addition, low self-esteem in the somatizing patient group becomes even lower if those patients are depressed. The present ndings suggest that although somatizing patients complain of ambiguous physical symptoms and they express dissatisfaction with their bodily functions and organs, they may have even more serious problems with their physical appear-

ance and self-esteem that could be hidden deep inside their physical bodily complaints. We therefore demonstrated a relationship between poor body image and somatization, but it is yet unclear whether poor body image predisposes to somatization.

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