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Psychiatry Research 246 (2016) 485–491

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Suicidality in patients with somatoform disorder – the speechless


expression of anger?
crossmark

Nora Kämpfera, , Sabine Staufenbiela, Ingo Wegenera, Stefanie Rambaua, Anne Sarah Urbacha,
Martin Mückeb, Franziska Geisera, Rupert Conrada
a
Department of Psychosomatic Medicine and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, 53105 Bonn, Germany
b
Department of Palliative Medicine, University Hospital of Bonn, Sigmund-Freud-Straße 25, 53105 Bonn, Germany

A R T I C L E I N F O A BS T RAC T

Keywords: Objective: To identify emotion-associated risk factors for suicidality in patients with somatoform disorders.
Suicidality Methods: A sample of 155 consecutive patients diagnosed with somatoform disorders at the Psychosomatic
Somatoform disorder Ambulance of Bonn University Hospital filled in several questionnaires including the Symptom Checklist 90-
Alexithymia Revised Version (SCL-90-R), the Toronto Alexithymia Scale (TAS-20), and the State Trait Anger Expression
Anger
Inventory (STAXI). Our aim was to compare patients with suicide attempts to patients without suicide attempts
via a MANCOVA (IV: Group; DV: SCL-90-R, TAS-20, STAXI; covariates: sex, age, depression, borderline
personality disorder).
Results: Lifetime suicide attempts were documented in 20 patients (12.9%), current active suicidal ideation in
33.6%, and thoughts of death or dying in 55.9%. Patients with lifetime suicide attempts showed significantly
more psychological distress, a significantly higher alexithymia sum score, a significantly higher score on trait
anger, state anger, and a stronger tendency to express anger.
Conclusion: Somatoform disorder patients with lifetime suicide attempts might have greater difficulties in
identifying and describing emotions, and a tendency to intensely experience and express anger. Future
longitudinal studies should further investigate possible links between difficulties in coping with anger and
suicidality to improve prophylaxis and treatment of suicidal behaviour in somatoform disorder patients.

1. Introduction researchers also have postulated elevated suicidality in patients with


somatoform disorders (Chioqueta and Stiles, 2004; Morrison and
Patients suffering from medically unexplained symptoms (MUS) Herbstein, 1988; Purtell et al., 1951; Woodruff et al., 1972).
and somatoform disorders are common, and adequate diagnostics and Recently, Klerk et al. (2011) investigated psychiatric outpatients and
therapy still remain challenging (Creed and Barsky, 2004; Haller et al., found that 45% of 461 somatoform disorder patients reported lifetime
2015; Hartman et al., 2009). Patients as well as practitioners often deliberate self-harm or current self-harm and suicidal ideation. It
focus on excluding somatic etiologies which causes high costs and should be mentioned that their findings were not corrected for
undervalues mental aspects and their therapeutic implications. In psychiatric comorbidities. Furthermore, the association between sui-
general, patients diagnosed with somatoform disorders show high cidality and somatoform complaints was found in psychiatric out-
rates of psychiatric comorbidities, especially of depression and anxiety patients and also in primary care patients who visited general practi-
disorders (de Waal et al., 2004; Henningsen et al., 2003; Löwe et al., tioners (Wiborg et al., 2013a, 2013b), indicating a considerable
2008; Mergl et al., 2007), and are likely to have a large disease burden relevance for everyday clinical practice. Wiborg et al. (2013a) revealed
and quality of life decrements (Mack et al., 2015). high suicidality rates in these primary care patients diagnosed with
So far, only few studies have tried to investigate the severity of somatoform disorders: 37% of them reported current thoughts of
courses, outcome, and associated aspects such as self-harm or suicid- wishing they were dead or hurting themselves, 24% showed active
ality in patients with MUS or somatoform disorders. A recent study by suicidal thoughts during the six months preceding the survey, and 18%
Park et al. (2012) revealed elevated suicidality (ideation, plans, had suicide attempts in the prolonged past. Comorbid severe depres-
attempts) in patients suffering from medically unexplained. Several sion was significantly higher in patients with suicidal ideation. The


Corresponding author.
E-mail address: nora.kaempfer@ukb.uni-bonn.de (N. Kämpfer).

http://dx.doi.org/10.1016/j.psychres.2016.10.022
Received 25 February 2016; Received in revised form 28 September 2016; Accepted 16 October 2016
Available online 17 October 2016
0165-1781/ © 2016 Elsevier Ireland Ltd. All rights reserved.

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N. Kämpfer et al. Psychiatry Research 246 (2016) 485–491

authors also showed that dysfunctional illness perceptions in somato- were conducted from January 2013 until July 2015. The study was
form disorder patients were associated with suicidal ideation and approved by the local ethics committee and informed consent was
therefore assumed that specific cognitive processes might play an obtained from all subjects. Patients were diagnosed by experienced
important role in developing suicidal ideation, irrespective of comorbid clinical experts at the Clinic for Psychosomatic Medicine and
depression. Psychotherapy, University of Bonn, Germany.
According to these findings, suicidality is an underestimated Of the 155 patients, 78 patients currently suffered from a somato-
problem in somatoform disorders. This is mirrored in a lack of studies form pain disorder (50.3%), 28 patients from a somatoform autonomic
investigating predictors and specific risk factors, apart from the dysfunction (18.1%), 26 patients from an undifferentiated somatoform
influence of comorbid depression or other psychiatric diagnoses. disorder (16.8%), 10 from other somatoform disorders (6.5%), 8
Several authors who have investigated suicidality in psychiatric patients from a somatization disorder (5.2%), and 5 patients from a
patients with other diagnoses than somatoform disorders revealed hypochondric disorder (3.2%).
specific emotions (e.g. anger) to be associated with suicidality (e.g.
Daniel et al., 2009; Evren et al., 2011; Giegling et al., 2009; Horesh 2.2. Diagnostic process
et al., 1997). In addition to general risk factors, such as previous
suicide attempts and certain sociodemographic factors, a current For diagnostic purpose we used the Structured Clinical Interview
review about suicide and associated risk factors (Turecki and Brent, for DSM-IV-axis I (SCID-I) to screen for psychiatric disorders and the
2015) underlines the relevance of specific emotions (e.g. aggression, Structured Clinical Interview for DSM-IV-axis II (SCID-II) to screen
anxiety) and personality-based competences in affective regulation. for paranoid and borderline personality disorders. A member of our
The authors assumed that in addition to ‘distal/predisposing’ risk clinical expert team took a 60–90 min lasting detailed psychiatric
factors (e.g. genetics, early-life adversity) and ‘proximal/precipitating’ history which included a semi-structered interview based on the ICD-
risk factors (e.g. current life events, psychopathologies, substance 10 criteria. According to ICD-10 criteria a somatoform disorder was
misuse), personality traits and cognitive styles could be seen as not assigned if the existing “physical symptoms were explained by any
‘developmental’ or ‘mediating’ risk factors for suicidality. detectable physical disorder” (WHO, 1992). Before assigning definitive
Somatoform disorders are considered to be closely linked to deviant diagnoses, they were discussed in our weekly team meeting and cross-
emotion perception and deficits in affect regulation (e.g. van Dijke and checked by a supervising senior physician with long year clinical
Ford, 2015; Waller and Scheidt, 2006), and research has shown that experience.
the amount of anger correlates with chronic pain (Castelli et al., 2013;
Greenwood et al., 2003; Sayar et al., 2004; Trost et al., 2012;). 2.3. Questionnaires
Regarding the above mentioned role of anger and aggression in suicidal
patients, it seems a promising approach to focus on these aspects in the Demographic data were obtained using a self-report questionnaire
examination of specific suicidality predictors in suicidal somatoform which assessed age, sex, level of education, employment status,
disorder patients. comorbid illnesses, and duration of complaints. It also included a
Interestingly, several authors have emphasized an important con- question for lifetime suicidal attempts (‘Have you ever attempted
nection between personality-based difficulties in identifying and ver- suicide?’).
balizing emotions, for which Nemiah and Sifneos coined the term
alexithymia (Nemiah and Sifneos, 1970; Sifneos, 1973; Taylor, 2000a; 2.3.1. SCL-90-R
Taylor et al., 1991), and somatoform disorders (e.g. Burba et al., 2006; The Hopkins Symptom Checklist 90, Revised Version (SCL-90-R)
Cox et al., 1994; de Gucht and Heiser, 2003; Koelen et al., 2015; (Derogatis, 1992) is a 90-item self-report questionnaire used to assess
Mattila et al., 2008; Waller and Scheidt, 2006). Recent research has symptoms of psychopathology and was used in its German version
found increasing evidence for a positive association between alexithy- (Franke, 2002). Each item is rated on a five-point Likert scale ranging
mia and suicidality. Thus, Hintikka et al. (2004) showed in a general from’not at all‘ to’extremely‘ (0–4). Nine subscales can be calculated to
population sample alexithymia to be associated with the presence of describe the extent of somatization, obsessive–compulsiveness, inter-
suicidal ideation even after adjustment for several psychosocial factors personal sensitivity, depression, anxiety, anger-hostility, phobic anxi-
and depression. Other studies have revealed a positive correlation ety, paranoid ideation, and psychoticism. In addition, the overall
between alexithymia and suicidality in the subsequent psychiatric psychological distress was measured via the Global Severity Index
subpopulations: patients with alcoholism (Sakuraba et al., 2005), (GSI). The questionnaire includes an item asking for active suicidal
eating disorders (Alpaslan et al., 2015; Carano et al., 2012), panic ideation (‘thoughts of ending your life’). In our study, presence of active
disorder (Iancu et al., 2001), generalized anxiety disorder (Berardis suicidal ideation was registered for all patients rating the mentioned
et al., 2015), post-traumatic stress disorder (Kušević et al., 2015), and item with at least 1 (‘a little bit’). Another item is asking for ‘thoughts of
schizophrenia (Marasco et al., 2011). However, this relationship has death or dying’ and may hint at passive suicidal ideation. In our study
not been investigated in somatoform disorder patients. we distinguished between moderate (item rated with 1–2) and intense
Against this backdrop, the aim of this study was to investigate (item rated with 3–4) thoughts of death or dying.
possible associations between suicidality and difficulties in identifying
emotions and coping with anger in patients with somatoform dis- 2.3.2. TAS-20
orders. We hypothesize that somatoform disorder patients with lifetime The Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994a,
suicide attempts show higher general distress and alexithymia levels 1994b; Taylor et al., 1988, 1990) is a 20-item self-report questionnaire
and differ in anger experience and management from patients without used to detect the extent of alexithymia and was used in its German
lifetime suicide attempts. version (Bach et al., 1996).
Each item is rated on a five-point Likert scale ranging from ‘strongly
2. Methods disagree’ to ‘strongly agree’. The established German version of the
questionnaire is corresponding to the translation by Bach et al. (1996).
2.1. Sample A higher score on the TAS-20 indicates a higher level of alexithymia.
Three subscales (TAS I: ‘identifying and discriminating feelings/emo-
A sample of 155 consecutive outpatients diagnosed with somato- tions’, TAS II: ‘communicating feelings/emotions’, TAS III: ‘externally
form disorders at the Psychosomatic Ambulance of Bonn University oriented thinking style’), and a total alexithymia score can be calcu-
Hospital was enrolled in this study. Recruitment and data collection lated. The TAS-20 uses a cutoff scoring system, and usually a total

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N. Kämpfer et al. Psychiatry Research 246 (2016) 485–491

Fig. 1. Global Severity Index (GSI) and subscales somatization, obsessive–compulsiveness (obs.-comp.), interpersonal sensitivity (interpers. sens.), depression, anxiety, anger-hostility
(hostility), phobic anxiety, paranoid ideation (paranoid ideat.), and psychoticism of the Symptom Checklist 90-Revised (SCL) for patients with and without suicide attempts. Data are
presented as mean and standard deviation. *, p < .05; **, p < .01; ***, p < .001.

alexithymia score equal to or less than 51 is considered as non- Multivariate Analysis of Covariance with sex, age, current depression,
alexithymic, a total score between 51 and 60 is considered as slightly and borderline personality disorder as covariates was run to prevent
alexithymic, and a score greater than or equal to 61 is considered as the effects of multiple testing. Data are presented as mean (M) and
alexithymic (Bagby et al., 1994a). standard deviation (SD), unless otherwise indicated. Effect sizes were
calculated using Cohen's d and Cramer's phi for continuous and
2.3.3. STAXI dichotomous variables, respectively.
The State-Trait Anger Expression Inventory (Spielberger, 1988) is In analyses on the SCL-90-R-items regarding suicidality, three
a 44-item self-report questionnaire that measures the extent of anger persons of the 155 did not provide answers. Therefore analyses on
and anger expression and was used in its German version the SCL-90-R were run on the remaining 152 patients. Complete data
(Schwenkmezger et al., 1992). Each item is rated on a four-point on duration of somatic complaints was collected in 118 patients and of
Likert scale ranging from ‘not at all’ to ‘very much so’ for the state anger mental complaints in 81 patients. Apart from these missings, all data
items and from ‘almost never’ to ‘almost always’ for the trait anger and were complete.
anger expression items. Values can be calculated for state anger (SA),
representing the currently experienced anger, and trait anger (TA), 3. Results
representing the overall experienced anger. The value for trait anger
consists of two subscales: angry temperament (TA/T) and angry 3.1. Sample characteristics and socio-demographic data
reaction (TA/R). In addition, three subscales are calculated which
display the frequency of specific anger expression: anger in (AI), anger The mean age of patients enrolled in this study was 42.18 years
out (AO), and anger control (AC). People with an elevated score on AI (SD=15.72) with a range from 17 to 79 years. The sample consisted of
often suffer anger but are used to keeping their angry feelings inside, 57.4% females. The mean of duration of somatic complaints was 8.4
suppress them and seldom show their angry feelings in a verbal or years (SD=9.38) and of mental complaints 8.2 years (SD=9.71).
physical way. An elevated AI score therefore indicates a discrepancy Between the two subgroups (presence or absence of lifetime suicide
between experienced anger and observable anger. People with an attempts), there was no significant difference concerning age, sex,
elevated AO score often suffer anger and are likely to express their comorbid depression, anxiety disorder, and borderline personality
angry feelings towards other objects/persons. People with an elevated disorder. There were significant group differences concerning all
score on AC are considered to often control their angry feelings to a subscales of the SCL-90-R, see Fig. 1. For further sample character-
high extent. istics, see Table 1.

2.4. Statistical analyses 3.2. Suicidality in somatoform disorder patients

Statistical analyses were run with SPSS (Statistical Package for Current active suicidal ideation was detected in 33.6% of the
Social Science, Version 22). All significance levels were set at p < .05 patients, current thoughts of death or dying were detected in 55.9%
and all analyses were performed as two-tailed tests. (34.8% moderate, 21.1% intense). At least one lifetime suicide attempt
The enrolled somatoform disorder patients were divided into two was documented in 20 (12.9%) of the patients. Both current active
subgroups, based on absence or presence of lifetime suicide attempts. suicidal ideation and thoughts of death or dying were significantly
Analyses on subgroup differences regarding age, sex, kind of somato- more frequent in the subgroup of suicide attempters (p=.016 and
form disorder, comorbid depression, comorbid anxiety disorder, co- p=.031, respectively).
morbid borderline personality disorder, current suicidal ideation,
current thoughts of death or dying, psychological distress, subscales 3.3. Suicidality and associated psychological parameters
of SCL-90-R, alexithymia, and anger dimensions were conducted using
Fisher's Exact Test and ANOVAs. To determine the association of Results of the MANCOVA showed that somatoform disorder
lifetime suicide attempts in patients with a somatoform disorder and patients with lifetime suicide attempts compared to somatoform
psychological distress, alexithymia, and anger dimensions, a disorder patients without suicide attempts have more psychological

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N. Kämpfer et al. Psychiatry Research 246 (2016) 485–491

Table 1
Group characteristics.

Somatoform disorder
patients (n=155)

Suicide No suicide p-Value Effect size


attempts attempts
(n=20) (n=135)

Sociodemographic
data Fig. 3. Scores of the State-Trait Anger Expression Inventory (STAXI) for patients with
Age 42.30 42.16 .971 d = .01 and without suicide attempts. Scores are presented for state anger (SA), trait anger (TA),
(16.23) (15.71) angry temperament (TA/T), angry reaction (TA/R), anger in (AI), anger out (AO), and
Sex (Women) 14 (70%) 75 (55.6%) .333 Φ=.098 anger control (AO). Data are presented as mean and standard deviation. *, p < .05; **, p
Somatoform disorder 20 (100%) 135 (100%) < .01; ***, p < .001.
Somatoform pain 18 (90%) 60 (44.4%) < .001 Φ=.305
disorder
the latter group did not (M=53.48, SD=12.68). Concerning the subscale
Somatization disorder 0 (0%) 8 (5.9%) .597 Φ=.09
Undifferentiated 0 (0%) 26 (19.3%) .026 Φ=.173 ‘externally oriented thinking style’, there was no significant difference
somatoform disorder between the two groups, even though patients with lifetime suicide
Hypochondric 0 (0%) 5 (3.7%) .999 Φ=.07 attempts scored slightly higher (p > .1, d=.43). Certain anger dimen-
disorder sions were found to be elevated in patients with lifetime suicide
Somatoform 1 (5%) 27 (20%) .128 Φ=.131
autonomic
attempts compared to the patients without lifetime suicide attempts:
dysfunction they showed a higher score on trait anger (TA) (p=.003, d=.75), state
Other somatoform 1 (5%) 9 (6.7%) .999 Φ=.023 anger (SA) (p=.022, d=.62), angry temperament (TA/T) (p < .001,
disorders d=.97), and a stronger tendency to express anger towards other
persons or objects (AO) (p < .001, d=.97), see Fig. 3. All other p-values
Psychological
characteristics of the examined anger parameters did not reach significance (p > .1).
Comorbid depression 16 (80%) 83 (61.5%) .137 Φ=.129
Comorbid anxiety 7 (35%) 36 (26.7%) .433 Φ=.062
disorder 4. Discussion
Borderline personality 3 (15%) 6 (4.4%) .093 Φ=.151
disorder
4.1. Elevated suicidality in somatoform disorder patients
Active suicidal 11 (57.9%) 40 (30.1%) .021 Φ=.195
ideation (SCL-Item
15) The aim of this study was to investigate possible factors associated
Thoughts of death or 15 (78.9%) 70 (52.6%) .046 Φ=.175 with suicidality in patients diagnosed with somatoform disorders. We
dying (SCL-Item 59)
found that 12.9% of our patients stated at least one suicide attempt in
Moderate 5 (26.3%) 48 (36,1%) .453 Φ=.075
Intense 10 (52.6%) 22 (16.5%) .001 Φ=.293
their life. Current active suicidal ideation and thoughts of death or
dying were elevated and significantly more frequent in the subgroup of
Analyses on subgroup differences were conducted using Fisher's Exact Test and suicide attempters. These findings are in line with the revealed elevated
ANOVAs. Data are presented as mean (standard deviation) and as n (valid procent). suicidality in patients with somatoform disorders by Wiborg et al.
Effect sizes, Cohen’s d and Cramer's Φ are shown. SCL, Symptom Check List 90 Revised (2013a), who showed presence of suicidal ideation in 37% and lifetime
Version. Moderate thoughts of death and dying, score of 1–2 on SCL-Item 59; Intense
suicide attempts in 18% of their sample. Previous suicide attempts are
thoughts of death and dying, score of 3–4 on SCL-Item 59.
generally considered to be one of the most important risk factors for
committing suicide in the future (e.g. Turecki and Brent, 2015). Our
observation, that somatoform suicide attempters also showed elevated
current suicidal ideation, confirms this association.
We only found slight gender differences in our sample. Somatoform
disorders generally are considered to be markedly more frequent in
females (e.g. Jacobi et al., 2004; Linzer et al., 1996; Kroenke and
Spitzer, 1998; Tomasson et al., 1991) even though other studies have
found only small gender differences (e.g. de Waal et al., 2004; Ladwig
et al., 2001) or even equal gender distribution (Bener et al., 2010).
Recruitment in a population-based survey or in primary, secondary or
tertiary care centers may be at least partially responsible for these
Fig. 2. Toronto Alexithymia Scale (TAS) for patients with and without suicide attempts. differences. It could be argued that men are more likely to attend highly
Standardized mean scores (score divided by 20) are presented for the sum score of TAS specialized health care units (such as a university hospital), especially
(Sum) and the subsequent subscales: I) ‘identifying and discriminating feelings/
when suffering from severe symptoms. Furthermore, as there is a close
emotions’, II) ‘communicating feelings/emotions’, III) ‘externally oriented thinking
contact and cooperation between our clinic and other somatic depart-
style’. Data are presented as mean and standard deviation. *, p < .05; **, p < .01.
ments of the university hospital, a lot of male patients with a potential
psychosomatic genesis of their symptoms are referred to our clinic.
distress measured by GSI (p < .001, d=1.09), see Fig. 1 for detailed
This may reduce the threshold for consultancy of our psychosomatic
SCL-90-R results. The patients with lifetime suicide attempts also
department for male patients.
showed a higher alexithymia sum score (p=.002, d=.82), a higher
In our sample of somatoform disorder patients, the diagnosis of a
alexithymia subscale score in ‘identifying and discriminating feelings
somatoform pain disorder was the most frequent one. This is in line
and emotions’ (p=.001, d=.9), and a higher subscale score in ‘commu-
with previous findings (Jacobi et al., 2004), even if the frequency of
nicating feelings‘ (p=.038, d=.55) compared to patients without life-
subdiagnoses seems to depend highly on the investigated population
time suicide attempts (Fig. 2). The mean of the former group reached
and underlying diagnostic criteria (Haller et al., 2015; Fink et al.,
the cutoff for alexithymia (M=63.7, SD=12.24) whereas the mean of
2004). Our findings support the idea of a positive correlation between

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N. Kämpfer et al. Psychiatry Research 246 (2016) 485–491

medically unexplained chronic pain and suicidality, which has been and Ford, 2015). However, our findings indicate a tendency to under-
assumed before (Ilgen et al., 2013; Park et al., 2012). Other studies regulate angry emotions and act impulsively in a subgroup of somato-
have shown that pain but also other somatic symptoms which are not form patients. The intense experience of the bodily anger symptoms
fully explained by somatic illnesses were found to increase depression and inability to understand and adequately communicate the emo-
(Chakraborty et al., 2012; Jeong et al., 2014), and that severe somatic tional upheaval may increase internal tension and pave the path to
symptoms doubled the risk for suicidal intents in older adults (Jeong impotent fury. Angry outbursts may be experienced as inappropriate,
et al., 2014). These studies propose a link between unexplained somatic and possible negative reactions of others may increase feelings of
symptoms and suicidality. Even though the exact causal relationship helplessness. The inability to adequately communicate anger may
remains unclear, a reciprocal interaction appears probable; on the one ultimately result in the turning of anger against oneself. The suicide
hand, experience of pain may strengthen suicidal ideation through attempt may be considered as the non-verbal expression of anger due
corresponding thoughts and feelings (sadness, sorrow, despair, low self to a failure of intrapsychic and interpersonal communication.
esteem), and on the other hand, a depressive perspective with altered
attention, attribution, and behaviour may increase pain perception. 4.4. Treatment implications and future perspectives

4.2. Suicidality and associated psychological parameters Above presented ideas implicate that the evaluation of the person-
ality-based tendency to identify emotions and experience and regulate
4.2.1. Psychological distress anger can help to optimize the identification and treatment of patients
In our sample, patients with lifetime suicide attempts showed a at risk for suicidal behaviour. As a consequence the evaluation of anger
significantly elevated value of GSI, indicating more overall psychologi- regulation and alexithymia should be considered to be included in the
cal distress and quality of life decrements, which is in line with previous initial diagnostic assessment. To date, there is a lack of studies
findings (Mack et al., 2015). targeting techniques to enhance mentalization of emotions as well as
anger treatment in somatoform disorder patients, but the following
4.2.2. Alexithymia findings in other populations might be transferred to them: some
In patients with lifetime suicide attempts, we registered a higher studies have shown positive effects on anger and anger control through
alexithymia sum score as well as higher scores on the subscales group and individual cognitive-behavioural therapy (e.g. McCloskey
‘identifying and discriminating feelings and emotions’ and ‘commu- et al., 2008). Particularly informed skills training (e.g. Neacsiu et al.,
nicating feelings‘. This is in line with several studies which have shown 2014), and also specific mindfulness-based treatments (e.g. Fix, 2013)
an association between alexithymia and suicidality in other populations seem to have positive influence on emotional awareness and anger
(Alpaslan et al., 2015; Berardis et al., 2015; Carano et al., 2012; management. There is also evidence that several medications (espe-
Hintikka et al., 2004; Iancu et al., 2001; Kušević et al., 2015; Marasco cially atypical antipsychotics and anticonvulsants) may reduce anger
et al., 2011; Sakuraba et al., 2005). Development of psychopathologies and impulsivity (Nickel et al., 2007; Scheltema Beduin and de Haan,
and mal-adaptive styles of emotion regulation are generally considered 2010; Leiberich et al., 2008; Nickel and Loew, 2008).
to be associated with alexithymia (e.g. Conrad et al., 2009; Taylor, Future longitudinal studies would be of great use giving insight on
2000b; Terock et al., 2015). More specifically, in somatoform disorder dynamics of anger experience, anger management, and its influence on
patients, coping deficits were found to be associated with alexithymia, suicidality in somatoform disorder patients. It would be interesting to
respectively elevated TAS-20 scores (Tominaga et al., 2014). explore how these variables evolve and interact over time, and how
Somatoform disorder patients are used to paying attention to and they are influenced by external factors (both life events and specific
therefore communicate their somatic complaints instead of their psychotherapeutical treatment). Future studies should also investigate
emotions (Longarzo et al., 2015). The psychological construct of additional factors that may contribute to suicidal behaviour in somato-
somatosensory amplification has been used to describe a specific form disorder patients and try to identify possible moderating and
tendency of somatoform disorder patients to focus on normal bodily mediating factors, such as personality dimensions associated with
symptoms thereby experiencing them as more intense and threatening impulsivity, attachment style, mentalization and communication skills.
(Barsky et al., 1988). Thus, attention is centered around the association
between bodily symptoms and organic illness, and diverted from other 4.5. Limitations
inward processes. Relevant distressing emotions remain unidentified
and are not communicated adequately. As our study uses a cross-sectional design, we cannot claim to
present causal relationships. Above presented ideas can only be
4.2.3. Anger dimensions considered first approaches and may contribute to concepts of further
A connection between anger/anger associated behaviour and studies.
suicide has been assumed in a variety of psychiatric disorders (see Diagnoses were made by conducting semi-structered interview
e.g. Brezo et al., 2006; Daniel et al., 2009; Evren et al., 2011; Giegling based on the ICD-10 criteria and using the SCID-I and parts of the
et al., 2009; Horesh et al., 1997; Swogger et al., 2011). Our findings SCID-II for screening intentions. We did not use further instruments
regarding elevated anger dimensions indicate that somatoform patients for assigning somatoform disorder diagnoses (e.g. Patient Health
with lifetime suicide attempts experience more overall anger and show Questionnaire -15).
a tendency to impulsively express anger even though the emotion Unfortunately our data on duration of illness and duration of
might not be well understood. general somatic and mental complaints were incomplete so that we
were unable to investigate how these aspects influence suicidal
4.3. Emotional underregulation behaviour.
Data was obtained by using several self-reporting questionnaires.
Putting all pieces together, one might hypothesize that somatoform This can be seen critically bearing in mind that alexithymic patients are
disorder patients with higher levels of alexithymia – as well as higher considered to be less introspective. Particularly the TAS-20 question-
levels of overall anger – experience the anger-associated bodily naire has methodological limitations because patients can only report
symptoms particularly intense and suffer a strong negative strain. In about consciously apparent deficits in identifying and communicating
contrast to other psychopathologies, such as borderline personality feelings. It has to be assumed that not the exact amount and not all
disorder, somatoform disorders are not considered to typically go along aspects of alexithymia (e.g. fantasy aspect, externally oriented thinking
with an underregulation of feelings (van Dijke et al., 2010; van Dijke style) can be captured adequately by the TAS-20 questionnaire (e.g.

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considered to be one of the main risk factors for future attempts, which somatoform disorder patients with chronic pain. J. Psychosom. Res. 38 (6),
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our group classification and allows assumptions about suicidality- Daniel, S.S., Goldston, D.B., Erkanli, A., Franklin, J.C., Mayfield, A.M., 2009. Trait anger,
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Conflicts of interest
Beltz Test Gesellschaft, Göttingen.
Giegling, I., Olgiati, P., Hartmann, A.M., Calati, R., Möller, H.-J., Rujescu, D., Serretti, A.,
None. 2009. Personality and attempted suicide. Analysis of anger, aggression and
impulsivity. J. Psychiatr. Res. 43 (16), 1262–1271.
Greenwood, K.A., Thurston, R., Rumble, M., Waters, S.J., Keefe, F.J., 2003. Anger and
Disclosure statement persistent pain: current status and future directions. Pain 103 (1–2), 1–5.
Haller, H., Cramer, H., Lauche, R., Dobos, G., 2015. Somatoform disorders and medically
The authors have nothing to disclose. unexplained symptoms in primary care. Dtsch. Ärzteblatt Int. 112 (16), 279–287.
Hartman, T.C., Borghuis, M.S., Lucassen, Peter, L.B.J., van de Laar, Floris, A., Speckens,
A.E., van Weel, C., 2009. Medically unexplained symptoms, somatisation disorder
Acknowledgements and hypochondriasis: course and prognosis. A systematic review. J. Psychosom. Res.
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Henningsen, P., Zimmermann, T., Sattel, H., 2003. Medically unexplained physical
None. symptoms, anxiety, and depression: a meta-analytic review. Psychosom. Med. 65 (4),
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