Psychiatry Research 246 (2016) 485–491

Contents lists available at ScienceDirect

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

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

Downloaded for Mahasiswa KTI UKDW (mhsktiukdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 08, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
N. Kämpfer et al.
authors also showed that dysfunctional illness perceptions in somato-
form disorder patients were associated with suicidal ideation and
therefore assumed that specific cognitive processes might play an
important role in developing suicidal ideation, irrespective of comorbid
depression.
According to these findings, suicidality is an underestimated
problem in somatoform disorders. This is mirrored in a lack of studies
investigating predictors and specific risk factors, apart from the
influence of comorbid depression or other psychiatric diagnoses.
Several authors who have investigated suicidality in psychiatric
patients with other diagnoses than somatoform disorders revealed
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
et al., 1997). In addition to general risk factors, such as previous
suicide attempts and certain sociodemographic factors, a current
review about suicide and associated risk factors (Turecki and Brent,
2015) underlines the relevance of specific emotions (e.g. aggression,
anxiety) and personality-based competences in affective regulation.
The authors assumed that in addition to ‘distal/predisposing’ risk
factors (e.g. genetics, early-life adversity) and ‘proximal/precipitating’
risk factors (e.g. current life events, psychopathologies, substance
misuse), personality traits and cognitive styles could be seen as
‘developmental’ or ‘mediating’ risk factors for suicidality.
Somatoform disorders are considered to be closely linked to deviant
emotion perception and deficits in affect regulation (e.g. van Dijke and
Ford, 2015; Waller and Scheidt, 2006), and research has shown that
the amount of anger correlates with chronic pain (Castelli et al., 2013;
Greenwood et al., 2003; Sayar et al., 2004; Trost et al., 2012;).
Regarding the above mentioned role of anger and aggression in suicidal
patients, it seems a promising approach to focus on these aspects in the
examination of specific suicidality predictors in suicidal somatoform
disorder patients.
Interestingly, several authors have emphasized an important con-
nection between personality-based difficulties in identifying and ver-
balizing emotions, for which Nemiah and Sifneos coined the term
alexithymia (Nemiah and Sifneos, 1970; Sifneos, 1973; Taylor, 2000a;
Taylor et al., 1991), and somatoform disorders (e.g. Burba et al., 2006;
Cox et al., 1994; de Gucht and Heiser, 2003; Koelen et al., 2015;
Mattila et al., 2008; Waller and Scheidt, 2006). Recent research has
found increasing evidence for a positive association between alexithy-
mia and suicidality. Thus, Hintikka et al. (2004) showed in a general
population sample alexithymia to be associated with the presence of
suicidal ideation even after adjustment for several psychosocial factors
and depression. Other studies have revealed a positive correlation
between alexithymia and suicidality in the subsequent psychiatric
subpopulations: patients with alcoholism (Sakuraba et al., 2005),
eating disorders (Alpaslan et al., 2015; Carano et al., 2012), panic
disorder (Iancu et al., 2001), generalized anxiety disorder (Berardis
et al., 2015), post-traumatic stress disorder (Kušević et al., 2015), and
schizophrenia (Marasco et al., 2011). However, this relationship has
not been investigated in somatoform disorder patients.
Against this backdrop, the aim of this study was to investigate
possible associations between suicidality and difficulties in identifying
emotions and coping with anger in patients with somatoform dis-
orders. We hypothesize that somatoform disorder patients with lifetime
suicide attempts show higher general distress and alexithymia levels
and differ in anger experience and management from patients without
lifetime suicide attempts.
2. Methods
2.1. Sample
A sample of 155 consecutive outpatients diagnosed with somato-
form disorders at the Psychosomatic Ambulance of Bonn University
Hospital was enrolled in this study. Recruitment and data collection
486
Downloaded for Mahasiswa KTI UKDW (mhsktiukdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 08, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Psychiatry Research 246 (2016) 485–491
were conducted from January 2013 until July 2015. The study was
approved by the local ethics committee and informed consent was
obtained from all subjects. Patients were diagnosed by experienced
clinical experts at the Clinic for Psychosomatic Medicine and
Psychotherapy, University of Bonn, Germany.
Of the 155 patients, 78 patients currently suffered from a somato-
form pain disorder (50.3%), 28 patients from a somatoform autonomic
dysfunction (18.1%), 26 patients from an undifferentiated somatoform
disorder (16.8%), 10 from other somatoform disorders (6.5%), 8
patients from a somatization disorder (5.2%), and 5 patients from a
hypochondric disorder (3.2%).
2.2. Diagnostic process
For diagnostic purpose we used the Structured Clinical Interview
for DSM-IV-axis I (SCID-I) to screen for psychiatric disorders and the
Structured Clinical Interview for DSM-IV-axis II (SCID-II) to screen
for paranoid and borderline personality disorders. A member of our
clinical expert team took a 60–90 min lasting detailed psychiatric
history which included a semi-structered interview based on the ICD-
10 criteria. According to ICD-10 criteria a somatoform disorder was
not assigned if the existing “physical symptoms were explained by any
detectable physical disorder” (WHO, 1992). Before assigning definitive
diagnoses, they were discussed in our weekly team meeting and cross-
checked by a supervising senior physician with long year clinical
experience.
2.3. Questionnaires
Demographic data were obtained using a self-report questionnaire
which assessed age, sex, level of education, employment status,
comorbid illnesses, and duration of complaints. It also included a
question for lifetime suicidal attempts (‘Have you ever attempted
suicide?’).
2.3.1. SCL-90-R
The Hopkins Symptom Checklist 90, Revised Version (SCL-90-R)
(Derogatis, 1992) is a 90-item self-report questionnaire used to assess
symptoms of psychopathology and was used in its German version
(Franke, 2002). Each item is rated on a five-point Likert scale ranging
from’not at all‘ to’extremely‘ (0–4). Nine subscales can be calculated to
describe the extent of somatization, obsessive–compulsiveness, inter-
personal sensitivity, depression, anxiety, anger-hostility, phobic anxi-
ety, paranoid ideation, and psychoticism. In addition, the overall
psychological distress was measured via the Global Severity Index
(GSI). The questionnaire includes an item asking for active suicidal
ideation (‘thoughts of ending your life’). In our study, presence of active
suicidal ideation was registered for all patients rating the mentioned
item with at least 1 (‘a little bit’). Another item is asking for ‘thoughts of
death or dying’ and may hint at passive suicidal ideation. In our study
we distinguished between moderate (item rated with 1–2) and intense
(item rated with 3–4) thoughts of death or dying.
2.3.2. TAS-20
The Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994a,
1994b; Taylor et al., 1988, 1990) is a 20-item self-report questionnaire
used to detect the extent of alexithymia and was used in its German
version (Bach et al., 1996).
Each item is rated on a five-point Likert scale ranging from ‘strongly
disagree’ to ‘strongly agree’. The established German version of the
questionnaire is corresponding to the translation by Bach et al. (1996).
A higher score on the TAS-20 indicates a higher level of alexithymia.
Three subscales (TAS I: ‘identifying and discriminating feelings/emo-
tions’, TAS II: ‘communicating feelings/emotions’, TAS III: ‘externally
oriented thinking style’), and a total alexithymia score can be calcu-
lated. The TAS-20 uses a cutoff scoring system, and usually a total
N. Kämpfer et al.
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-
alexithymic, a total score between 51 and 60 is considered as slightly
alexithymic, and a score greater than or equal to 61 is considered as
alexithymic (Bagby et al., 1994a).
2.3.3. STAXI
The State-Trait Anger Expression Inventory (Spielberger, 1988) is
a 44-item self-report questionnaire that measures the extent of anger
and anger expression and was used in its German version
(Schwenkmezger et al., 1992). Each item is rated on a four-point
Likert scale ranging from ‘not at all’ to ‘very much so’ for the state anger
items and from ‘almost never’ to ‘almost always’ for the trait anger and
anger expression items. Values can be calculated for state anger (SA),
representing the currently experienced anger, and trait anger (TA),
representing the overall experienced anger. The value for trait anger
consists of two subscales: angry temperament (TA/T) and angry
reaction (TA/R). In addition, three subscales are calculated which
display the frequency of specific anger expression: anger in (AI), anger
out (AO), and anger control (AC). People with an elevated score on AI
often suffer anger but are used to keeping their angry feelings inside,
suppress them and seldom show their angry feelings in a verbal or
physical way. An elevated AI score therefore indicates a discrepancy
between experienced anger and observable anger. People with an
elevated AO score often suffer anger and are likely to express their
angry feelings towards other objects/persons. People with an elevated
score on AC are considered to often control their angry feelings to a
high extent.
2.4. Statistical analyses
Statistical analyses were run with SPSS (Statistical Package for
Social Science, Version 22). All significance levels were set at p < .05
and all analyses were performed as two-tailed tests.
The enrolled somatoform disorder patients were divided into two
subgroups, based on absence or presence of lifetime suicide attempts.
Analyses on subgroup differences regarding age, sex, kind of somato-
form disorder, comorbid depression, comorbid anxiety disorder, co-
morbid borderline personality disorder, current suicidal ideation,
current thoughts of death or dying, psychological distress, subscales
of SCL-90-R, alexithymia, and anger dimensions were conducted using
Fisher's Exact Test and ANOVAs. To determine the association of
lifetime suicide attempts in patients with a somatoform disorder and
psychological distress, alexithymia, and anger dimensions, a
487
Downloaded for Mahasiswa KTI UKDW (mhsktiukdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 08, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Psychiatry Research 246 (2016) 485–491
Multivariate Analysis of Covariance with sex, age, current depression,
and borderline personality disorder as covariates was run to prevent
the effects of multiple testing. Data are presented as mean (M) and
standard deviation (SD), unless otherwise indicated. Effect sizes were
calculated using Cohen's d and Cramer's phi for continuous and
dichotomous variables, respectively.
In analyses on the SCL-90-R-items regarding suicidality, three
persons of the 155 did not provide answers. Therefore analyses on
the SCL-90-R were run on the remaining 152 patients. Complete data
on duration of somatic complaints was collected in 118 patients and of
mental complaints in 81 patients. Apart from these missings, all data
were complete.
3. Results
3.1. Sample characteristics and socio-demographic data
The mean age of patients enrolled in this study was 42.18 years
(SD=15.72) with a range from 17 to 79 years. The sample consisted of
57.4% females. The mean of duration of somatic complaints was 8.4
years (SD=9.38) and of mental complaints 8.2 years (SD=9.71).
Between the two subgroups (presence or absence of lifetime suicide
attempts), there was no significant difference concerning age, sex,
comorbid depression, anxiety disorder, and borderline personality
disorder. There were significant group differences concerning all
subscales of the SCL-90-R, see Fig. 1. For further sample character-
istics, see Table 1.
3.2. Suicidality in somatoform disorder patients
Current active suicidal ideation was detected in 33.6% of the
patients, current thoughts of death or dying were detected in 55.9%
(34.8% moderate, 21.1% intense). At least one lifetime suicide attempt
was documented in 20 (12.9%) of the patients. Both current active
suicidal ideation and thoughts of death or dying were significantly
more frequent in the subgroup of suicide attempters (p=.016 and
p=.031, respectively).
3.3. Suicidality and associated psychological parameters
Results of the MANCOVA showed that somatoform disorder
patients with lifetime suicide attempts compared to somatoform
disorder patients without suicide attempts have more psychological
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

488

Downloaded for Mahasiswa KTI UKDW (mhsktiukdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 08, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
N. Kämpfer et al.
medically unexplained chronic pain and suicidality, which has been
assumed before (Ilgen et al., 2013; Park et al., 2012). Other studies
have shown that pain but also other somatic symptoms which are not
fully explained by somatic illnesses were found to increase depression
(Chakraborty et al., 2012; Jeong et al., 2014), and that severe somatic
symptoms doubled the risk for suicidal intents in older adults (Jeong
et al., 2014). These studies propose a link between unexplained somatic
symptoms and suicidality. Even though the exact causal relationship
remains unclear, a reciprocal interaction appears probable; on the one
hand, experience of pain may strengthen suicidal ideation through
corresponding thoughts and feelings (sadness, sorrow, despair, low self
esteem), and on the other hand, a depressive perspective with altered
attention, attribution, and behaviour may increase pain perception.
4.2. Suicidality and associated psychological parameters
4.2.1. Psychological distress
In our sample, patients with lifetime suicide attempts showed a
significantly elevated value of GSI, indicating more overall psychologi-
cal distress and quality of life decrements, which is in line with previous
findings (Mack et al., 2015).
4.2.2. Alexithymia
In patients with lifetime suicide attempts, we registered a higher
alexithymia sum score as well as higher scores on the subscales
‘identifying and discriminating feelings and emotions’ and ‘commu-
nicating feelings‘. This is in line with several studies which have shown
an association between alexithymia and suicidality in other populations
(Alpaslan et al., 2015; Berardis et al., 2015; Carano et al., 2012;
Hintikka et al., 2004; Iancu et al., 2001; Kušević et al., 2015; Marasco
et al., 2011; Sakuraba et al., 2005). Development of psychopathologies
and mal-adaptive styles of emotion regulation are generally considered
to be associated with alexithymia (e.g. Conrad et al., 2009; Taylor,
2000b; Terock et al., 2015). More specifically, in somatoform disorder
patients, coping deficits were found to be associated with alexithymia,
respectively elevated TAS-20 scores (Tominaga et al., 2014).
Somatoform disorder patients are used to paying attention to and
therefore communicate their somatic complaints instead of their
emotions (Longarzo et al., 2015). The psychological construct of
somatosensory amplification has been used to describe a specific
tendency of somatoform disorder patients to focus on normal bodily
symptoms thereby experiencing them as more intense and threatening
(Barsky et al., 1988). Thus, attention is centered around the association
between bodily symptoms and organic illness, and diverted from other
inward processes. Relevant distressing emotions remain unidentified
and are not communicated adequately.
4.2.3. Anger dimensions
A connection between anger/anger associated behaviour and
suicide has been assumed in a variety of psychiatric disorders (see
e.g. Brezo et al., 2006; Daniel et al., 2009; Evren et al., 2011; Giegling
et al., 2009; Horesh et al., 1997; Swogger et al., 2011). Our findings
regarding elevated anger dimensions indicate that somatoform patients
with lifetime suicide attempts experience more overall anger and show
a tendency to impulsively express anger even though the emotion
might not be well understood.
4.3. Emotional underregulation
Putting all pieces together, one might hypothesize that somatoform
disorder patients with higher levels of alexithymia – as well as higher
levels of overall anger – experience the anger-associated bodily
symptoms particularly intense and suffer a strong negative strain. In
contrast to other psychopathologies, such as borderline personality
disorder, somatoform disorders are not considered to typically go along
with an underregulation of feelings (van Dijke et al., 2010; van Dijke
489
Downloaded for Mahasiswa KTI UKDW (mhsktiukdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 08, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Psychiatry Research 246 (2016) 485–491
and Ford, 2015). However, our findings indicate a tendency to under-
regulate angry emotions and act impulsively in a subgroup of somato-
form patients. The intense experience of the bodily anger symptoms
and inability to understand and adequately communicate the emo-
tional upheaval may increase internal tension and pave the path to
impotent fury. Angry outbursts may be experienced as inappropriate,
and possible negative reactions of others may increase feelings of
helplessness. The inability to adequately communicate anger may
ultimately result in the turning of anger against oneself. The suicide
attempt may be considered as the non-verbal expression of anger due
to a failure of intrapsychic and interpersonal communication.
4.4. Treatment implications and future perspectives
Above presented ideas implicate that the evaluation of the person-
ality-based tendency to identify emotions and experience and regulate
anger can help to optimize the identification and treatment of patients
at risk for suicidal behaviour. As a consequence the evaluation of anger
regulation and alexithymia should be considered to be included in the
initial diagnostic assessment. To date, there is a lack of studies
targeting techniques to enhance mentalization of emotions as well as
anger treatment in somatoform disorder patients, but the following
findings in other populations might be transferred to them: some
studies have shown positive effects on anger and anger control through
group and individual cognitive-behavioural therapy (e.g. McCloskey
et al., 2008). Particularly informed skills training (e.g. Neacsiu et al.,
2014), and also specific mindfulness-based treatments (e.g. Fix, 2013)
seem to have positive influence on emotional awareness and anger
management. There is also evidence that several medications (espe-
cially atypical antipsychotics and anticonvulsants) may reduce anger
and impulsivity (Nickel et al., 2007; Scheltema Beduin and de Haan,
2010; Leiberich et al., 2008; Nickel and Loew, 2008).
Future longitudinal studies would be of great use giving insight on
dynamics of anger experience, anger management, and its influence on
suicidality in somatoform disorder patients. It would be interesting to
explore how these variables evolve and interact over time, and how
they are influenced by external factors (both life events and specific
psychotherapeutical treatment). Future studies should also investigate
additional factors that may contribute to suicidal behaviour in somato-
form disorder patients and try to identify possible moderating and
mediating factors, such as personality dimensions associated with
impulsivity, attachment style, mentalization and communication skills.
4.5. Limitations
As our study uses a cross-sectional design, we cannot claim to
present causal relationships. Above presented ideas can only be
considered first approaches and may contribute to concepts of further
studies.
Diagnoses were made by conducting semi-structered interview
based on the ICD-10 criteria and using the SCID-I and parts of the
SCID-II for screening intentions. We did not use further instruments
for assigning somatoform disorder diagnoses (e.g. Patient Health
Questionnaire -15).
Unfortunately our data on duration of illness and duration of
general somatic and mental complaints were incomplete so that we
were unable to investigate how these aspects influence suicidal
behaviour.
Data was obtained by using several self-reporting questionnaires.
This can be seen critically bearing in mind that alexithymic patients are
considered to be less introspective. Particularly the TAS-20 question-
naire has methodological limitations because patients can only report
about consciously apparent deficits in identifying and communicating
feelings. It has to be assumed that not the exact amount and not all
aspects of alexithymia (e.g. fantasy aspect, externally oriented thinking
style) can be captured adequately by the TAS-20 questionnaire (e.g.
N. Kämpfer et al.
Kooiman et al., 2002; Lane et. al, 2015).
All enrolled patients complied with criteria for somatoform dis-
orders at the time of consultation. However, we do not know whether
these patients already suffered from a somatoform disorder at the time
of their suicide attempt. Nevertheless, a previous suicide attempt is
considered to be one of the main risk factors for future attempts, which
was confirmed in our study by a significantly higher current suicidal
ideation in somatoform patients with suicide attempts. This supports
our group classification and allows assumptions about suicidality-
associated psychological parameters in patients with (current) somato-
form disorders.
5. Summary
In this study somatoform disorder patients with lifetime suicide
attempts show greater difficulties in identifying and describing emo-
tions and show a personality-based tendency to intensely experience
and express anger. The evaluation of individual anger regulation and
alexithymia should be considered to be included in the initial diag-
nostic assessment to optimize the identification of patients at risk for
suicidal behaviour. Aspects of anger management should then be
involved in treatment strategies.
Conflicts of interest
None.
Disclosure statement
The authors have nothing to disclose.
Acknowledgements
None.
References
Alpaslan, A.H., Soylu, N., Avci, K., Coşkun, K.Ş., Kocak, U., Taş, H.U., 2015. Disordered
eating attitudes, alexithymia and suicide probability among Turkish high school girls.
Psychiatry Res. 226 (1), 224–229.
Bach, M., Bach, D., Zwaan, M., de, Serim, M., Böhmer, F., 1996. Validierung der
deutschen Version der 20-Item Toronto-Alexithymie-Skala bei Normalpersonen und
psychiatrischen Patienten. Psychother. Psychosom. Med. Psychol. 46 (1), 23–28.
Bagby, R.M., Parker, J.D., Taylor, G.J., 1994a. The twenty-item Toronto Alexithymia
Scale–I. Item selection and cross-validation of the factor structure. J. Psychosom.
Res. 38 (1), 23–32.
Bagby, R.M., Taylor, G.J., Parker, J.D., 1994b. The twenty-item Toronto Alexithymia
Scale–II. Convergent, discriminant, and concurrent validity. J. Psychosom. Res. 38
(1), 33–40.
Barsky, A.J., Goodson, J.D., Lane, R.S., Cleary, P.D., 1988. The amplification of somatic
symptoms. Psychosom. Med. 50 (5), 510–519.
Bener, A., Ghuloum, S., Burgut, F.T., 2010. Gender differences in prevalence of
somatoform disorders in patients visiting primary care centers. J. Prim. Care
Community Health 1 (1), 37–42.
Berardis, D., de, Serroni, N., Campanella, D., Marini, S., Rapini, G., Valchera, A., Iasevoli,
F., Mazza, M., Fornaro, M., Perna, G., Di Iorio, G., Martinotti, G., Di Giannantonio,
M., 2015. Alexithymia, suicide ideation, C-reactive protein and serum lipid levels
among outpatients with generalized Anxiety Disorder. Arch. Suicide Res.: Off. J. Int.
Acad. Suicide Res..
Brezo, J., Paris, J., Turecki, G., 2006. Personality traits as correlates of suicidal ideation,
suicide attempts, and suicide completions: a systematic review. Acta Psychiatr.
Scand. 113 (3), 180–206.
Burba, B., Oswald, R., Grigaliunien, V., Neverauskiene, S., Jankuviene, O., Chue, P.,
2006. A controlled study of alexithymia in adolescent patients with persistent
somatoform pain disorder. Can. J. Psychiatry Rev. Can. Psychiatr. 51 (7), 468–471.
Carano, A., Berardis, D., de, Campanella, D., Serroni, N., Ferri, F., Di Iorio, G., Acciavatti,
T., Mancini, L., Mariani, G., Martinotti, G., Moschetta, F.S., Di Giannantonio, M.,
2012. Alexithymia and suicide ideation in a sample of patients with binge eating
disorder. J. Psychiatr. Pract. 18 (1), 5–11.
Castelli, L., Santis, F., de, Giorgi, I., de, Deregibus, A., Tesio, V., Leombruni, P., Granieri,
A., Debernardi, C., Torta, R., 2013. Alexithymia, anger and psychological distress in
patients with myofascial pain: a case-control study. Front. Psychol. 4, 490.
Chakraborty, K., Avasthi, A., Kumar, S., Grover, S., 2012. Psychological and clinical
correlates of functional somatic complaints in depression. Int. J. Soc. Psychiatry 58
490
Downloaded for Mahasiswa KTI UKDW (mhsktiukdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 08, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Psychiatry Research 246 (2016) 485–491
(1), 87–95.
Chioqueta, A.P., Stiles, T.C., 2004. Suicide risk in patients with somatization disorder.
Crisis 25 (1), 3–7.
Conrad, R., Wegener, I., Imbierowicz, K., Liedtke, R., Geiser, F., 2009. Alexithymia,
temperament and character as predictors of psychopathology in patients with major
depression. Psychiatry Res. 165 (1–2), 137–144.
Cox, B.J., Kuch, K., Parker, J.D., Shulman, I.D., Evans, R.J., 1994. Alexithymia in
somatoform disorder patients with chronic pain. J. Psychosom. Res. 38 (6),
523–527.
Creed, F., Barsky, A., 2004. A systematic review of the epidemiology of somatisation
disorder and hypochondriasis. J. Psychosom. Res. 56 (4), 391–408.
Daniel, S.S., Goldston, D.B., Erkanli, A., Franklin, J.C., Mayfield, A.M., 2009. Trait anger,
anger expression, and suicide attempts among adolescents and young adults: a
prospective study. J. Clin. Child Adolesc. Psychol.: Off. J. Soc. Clin. Child Adolesc.
Psychol. Am. Psychol. Assoc. Div. 53 38, 661–671.
de Gucht, V., Heiser, W., 2003. Alexithymia and somatisation: quantitative review of the
literature. J. Psychosom. Res. 54 (5), 425–434.
de Waal, M.W., Arnold, I.A., Eekhof, J.A., van Hemert, A.M., 2004. Somatoform
disorders in general practice: prevalence, functional impairment and comorbidity
with anxiety and depressive disorders. Br. J. Psychiatry.: J. Ment. Sci. 184, 470–476.
Derogatis, L.R., 1992. SCL-90-R: administration, scoring & procedures manual-II for
the R(evised) version and other instruments of the psychopathology rating scale
series 2nd ed.. Clinical Psychometric Research, Towson, MD.
Evren, C., Cinar, O., Evren, B., Celik, S., 2011. History of suicide attempt in male
substance-dependent inpatients and relationship to borderline personality features,
anger, hostility and aggression. Psychiatry Res. 190 (1), 126–131.
Fink, P., Hansen, M.S., Oxhoj, M.-L., 2004. The prevalence of somatoform disorders
among internal medical inpatients. J. Psychosom. Res. 56 (4), 413–418.
Fix, R.L., Fix, S.T., 2013. The effects of mindfulness-based treatments for aggression: a
critical review. Aggress. Violent Behav. 18 (2), 219–227.
Franke, G.H., 2002. SCL-90-R - Die Symptom-Checkliste von L. R. Derogatis 2nd ed..
Beltz Test Gesellschaft, Göttingen.
Giegling, I., Olgiati, P., Hartmann, A.M., Calati, R., Möller, H.-J., Rujescu, D., Serretti, A.,
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
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
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
and hypochondriasis: course and prognosis. A systematic review. J. Psychosom. Res.
66 (5), 363–377.
Henningsen, P., Zimmermann, T., Sattel, H., 2003. Medically unexplained physical
symptoms, anxiety, and depression: a meta-analytic review. Psychosom. Med. 65 (4),
528–533.
Hintikka, J., Honkalampi, K., Koivumaa-Honkanen, H., Antikainen, R., Tanskanen, A.,
Haatainen, K., Viinamäki, H., 2004. Alexithymia and suicidal ideation: a 12-month
follow-up study in a general population. Compr. Psychiatry 45 (5), 340–345.
Horesh, N., Rolnick, T., Iancu, I., Dannon, P., Lepkifker, E., Apter, A., Kotler, M., 1997.
Anger, impulsivity and suicide risk. Psychother. Psychosom. 66 (2), 92–96.
Iancu, I., Dannon, P.N., Poreh, A., Lepkifker, E., Grunhaus, L., 2001. Alexithymia and
suicidality in panic disorder. Compr. Psychiatry 42 (6), 477–481.
Ilgen, M.A., Kleinberg, F., Ignacio, R.V., Bohnert, A.S.B., Valenstein, M., McCarthy, J.F.,
Blow, F.C., Katz, I.R., 2013. Noncancer pain conditions and risk of suicide. JAMA
Psychiatry 70 (7), 692–697.
Jacobi, F., Wittchen, H.-U., Holting, C., Hofler, M., Pfister, H., Muller, N., Lieb, R., 2004.
Prevalence, co-morbidity and correlates of mental disorders in the general
population: results from the German Health Interview and Examination Survey
(GHS). Psychol. Med. 34 (4), 597–611.
Jeong, H.-G., Han, C., Park, M.H., Ryu, S.-H., Pae, C.-U., Lee, J.Y., Kim, S.H., Steffens,
D.C., 2014. Influence of the number and severity of somatic symptoms on the
severity of depression and suicidality in community-dwelling elders. Asia-Pac.
Psychiatry.: Off. J. Pac. Rim Coll. Psychiatr. 6 (3), 274–283.
Klerk, S., de, van Noorden, M.S., van Giezen, A.E., Spinhoven, P., den Hollander-
Gijsman, M.E., Giltay, E.J., Speckens, A.E.M., Zitman, F.G., 2011. Prevalence and
correlates of lifetime deliberate self-harm and suicidal ideation in naturalistic
outpatients: the Leiden Routine Outcome Monitoring study. J. Affect. Disord. 133
(1–2), 257–264.
Koelen, J.A., Eurelings-Bontekoe, E.H.M., Stuke, F., Luyten, P., 2015. Insecure
attachment strategies are associated with cognitive alexithymia in patients with
severe somatoform disorder. Int. J. Psychiatry Med. 49 (4), 264–278.
Kooiman, C.G., Spinhoven, P., Trijsburg, R.W., 2002. The assessment of alexithymia: a
critical review of the literature and a psychometric study of the Toronto Alexithymia
Scale- 20. J. Psychosom. Res. 53 (6), 1083–1090.
Kroenke, K., Spitzer, R.L., 1998. Gender differences in the reporting of physical and
somatoform symptoms. Psychosom. Med. 60 (2), 150–155.
Kušević, Z., Ćusa, B.V., Babić, G., Marčinko, D., 2015. Could alexithymia predict suicide
attempts - a study of Croatian war veterans with post-traumatic stress disorder.
Psychiatr. Danub. 27 (4), 420–423.
Ladwig, K.H., Marten-Mittag, B., Erazo, N., Gundel, H., 2001. Identifying somatization
disorder in a population-based health examination survey: psychosocial burden and
gender differences. Psychosomatics 42 (6), 511–518. http://dx.doi.org/10.1176/
appi.psy.42.6.511.
Lane, R.D., Weihs, K.L., Herring, A., Hishaw, A., Smith, R., 2015. Affective agnosia:
expansion of the alexithymia construct and a new opportunity to integrate and
N. Kämpfer et al.
extend Freud’s legacy. Neurosci. Biobehav. Rev. 55, 594–611.
Leiberich, P., Nickel, M.K., Tritt, K., Pedrosa Gil, F., 2008. Lamotrigine treatment of
aggression in female borderline patients, Part II: an 18-month follow-up. J.
Psychopharmacol. 22 (7), 805–808. http://dx.doi.org/10.1177/0269881107084004.
Linzer, M., Spitzer, R., Kroenke, K., Williams, J.B., Hahn, S., Brody, D., deGruy, F., 1996.
Gender, quality of life, and mental disorders in primary care: results from the
PRIME-MD 1000 study. Am. J. Med. 101 (5), 526–533.
Longarzo, M., D’Olimpio, F., Chiavazzo, A., Santangelo, G., Trojano, L., Grossi, D., 2015.
The relationships between interoception and alexithymic trait. The Self-Awareness
Questionnaire in healthy subjects. Front. Psychol. 6, 1149.
Löwe, B., Spitzer, R.L., Williams, J.B.W., Mussell, M., Schellberg, D., Kroenke, K., 2008.
Depression, anxiety and somatization in primary care: syndrome overlap and
functional impairment. Gen. Hosp. Psychiatry 30 (3), 191–199.
Mack, S., Jacobi, F., Beesdo-Baum, K., Gerschler, A., Strehle, J., Höfler, M., Busch, M.A.,
Maske, U., Hapke, U., Gaebel, W., Zielasek, J., Maier, W., Wittchen, H.-U., 2015.
Functional disability and quality of life decrements in mental disorders: results from
the Mental Health Module of the German Health Interview and Examination Survey
for Adults (DEGS1-MH). Eur. Psychiatry.: J. Assoc. Eur. Psychiatr. 30 (6), 793–800.
Marasco, V., Berardis, D., de, Serroni, N., Campanella, D., Acciavatti, T., Caltabiano, M.,
Olivieri, L., Rapini, G., Cicconetti, A., Carano, A., La Rovere, R., Di Iorio, G.,
Moschetta, F.S., Di Giannantonio, M., 2011. Alessitimia e rischio suicidario in
pazienti affetti da schizofrenia: risultati preliminari di uno studio trasversale. Riv.
Psichiatr. 46 (1), 31–37.
Mattila, A.K., Kronholm, E., Jula, A., Salminen, J.K., Koivisto, A.-M., Mielonen, R.-L.,
Joukamaa, M., 2008. Alexithymia and somatization in general population.
Psychosom. Med. 70 (6), 716–722.
McCloskey, M.S., Noblett, K.L., Deffenbacher, J.L., Gollan, J.K., Coccaro, E.F., 2008.
Cognitive-behavioral therapy for intermittent explosive disorder: a pilot randomized
clinical trial. J. Consult. Clin. Psychol. 76 (5), 876–886.
Mergl, R., Seidscheck, I., Allgaier, A.-K., Möller, H.-J., Hegerl, U., Henkel, V., 2007.
Depressive, anxiety, and somatoform disorders in primary care: prevalence and
recognition. Depress. Anxiety 24 (3), 185–195.
Morrison, J., Herbstein, J., 1988. Secondary affective disorder in women with
somatization disorder. Compr. Psychiatry 29 (4), 433–440.
Neacsiu, A.D., Eberle, J.W., Kramer, R., Wiesmann, T., Linehan, M.M., 2014. Dialectical
behavior therapy skills for transdiagnostic emotion dysregulation: a pilot
randomized controlled trial. Behav. Res. Ther. 59, 40–51.
Nemiah, J.C., Sifneos, P.E., 1970. Psychosomatic illness: a problem in communication.
Psychother. Psychosom. 18 (1), 154–160.
Nickel, M.K., Loew, T.H., Pedrosa Gil, F., 2007. Aripiprazole in treatment of borderline
patients, part II: an 18-month follow-up. Psychopharmacology 191 (4), 1023–1026.
Nickel, M.K., Loew, T.H., 2008. Treatment of aggression with topiramate in male
borderline patients, part II: 18-month follow-up. Eur. Psychiatry 23 (2), 115–117.
Park, S., Cho, M.J., Seong, S., Shin, S.Y., Sohn, J., Hahm, B.-J., Hong, J.P., 2012.
Psychiatric morbidities, sleep disturbances, suicidality, and quality-of-life in a
community population with medically unexplained pain in Korea. Psychiatry Res.
198 (3), 509–515.
Purtell, J.J., Robins, E., Cohen, M.E., 1951. Observations on clinical aspects of hysteria; a
quantitative study of 50 hysteria patients and 156 control subjects. J. Am. Med.
Assoc. 146 (10), 902–909.
Sakuraba, S., Kubo, M., Komoda, T., Yamana, J.-I., 2005. Suicidal ideation and
alexithymia in patients with alcoholism: a pilot study. Subst. Use Misuse 40 (6),
823–830.
Sayar, K., Gulec, H., Topbas, M., 2004. Alexithymia and anger in patients with
fibromyalgia. Clin. Rheumatol. 23 (5), 441–448.
491
Downloaded for Mahasiswa KTI UKDW (mhsktiukdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 08, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Psychiatry Research 246 (2016) 485–491
Scheltema Beduin, A., de Haan, L., 2010. Off-label second generation antipsychotics for
impulse regulation disorders: a review. Psychopharmacol. Bull. 43 (3), 45–81.
Schwenkmezger, P., Hodapp, V., Spielberger, C.D., 1992. Das State-Trait-
Ärgerausdrucks-Inventar STAXI: Handbuch, 1st ed. Huber, Bern, Göttingen,
Toronto
Sifneos, P.E., 1973. The prevalence of ‘alexithymic’ characteristics in psychosomatic
patients. Psychother. Psychosom. 22 (2), 255–262.
Spielberger, C.D., 1988. State-Trait Anger Expression Inventory: professional manual.
Psychological Assessment Resources, Odessa, Fla.
Swogger, M.T., You, S., Cashman-Brown, S., Conner, K.R., 2011. Childhood physical
abuse, aggression, and suicide attempts among criminal offenders. Psychiatry Res.
185 (3), 363–367.
Taylor, G.J., 2000a. Recent developments in alexithymia theory and research. Can. J.
Psychiatry Rev. Can. De. Psychiatr. 45 (2), 134–142.
Taylor, G.J., 2000b. Recent developments in alexithymia theory and research. Can. J.
Psychiatry Rev. Can. De. Psychiatr. 45 (2), 134–142.
Taylor, G.J., Bagby, R.M., Parker, J.D., 1991. The alexithymia construct. A potential
paradigm for psychosomatic medicine. Psychosomatics 32 (2), 153–164.
Taylor, G.J., Bagby, R.M., Ryan, D.P., Parker, J.D., 1990. Validation of the alexithymia
construct: a measurement-based approach. Can. J. Psychiatry Rev. Can. Psychiatr.
35 (4), 290–297.
Taylor, G.J., Bagby, R.M., Ryan, D.P., Parker, J.D., Doody, K.F., Keefe, P., 1988. Criterion
validity of the Toronto Alexithymia Scale. Psychosom. Med. 50 (5), 500–509.
Terock, J., Janowitz, D., Spitzer, C., Miertsch, M., Freyberger, H.J., Grabe, H.J., 2015.
Alexithymia and self-directedness as predictors of psychopathology and
psychotherapeutic treatment outcome. Compr. Psychiatry 62, 34–41.
Tomasson, K., Kent, D., Coryell, W., 1991. Somatization and conversion disorders:
comorbidity and demographics at presentation. Acta Psychiatr. Scand. 84 (3),
288–293.
Tominaga, T., Choi, H., Nagoshi, Y., Wada, Y., Fukui, K., 2014. Relationship between
alexithymia and coping strategies in patients with somatoform disorder.
Neuropsychiatr. Dis. Treat. 10, 55–62.
Trost, Z., Vangronsveld, K., Linton, S.J., Quartana, P.J., Sullivan, M.J.L., 2012. Cognitive
dimensions of anger in chronic pain. Pain 153 (3), 515–517.
Turecki, G., Brent, D.A., 2015. Suicide and suicidal behaviour. Lancet, London, England.
van Dijke, A., Ford, J.D., 2015. Adult attachment and emotion dysregulation in
borderline personality and somatoform disorders. Bord. Personal. Disord. Emot.
Dysregul. 2, 6.
van Dijke, A., Ford, J.D., van der Hart, O., van Son, M., van der Heijden, P., Bühring, M.,
2010. Affect dysregulation in borderline personality disorder and somatoform
disorder: differentiating under- and over-regulation. J. Personal. Disord. 24 (3),
296–311.
Waller, E., Scheidt, C.E., 2006. Somatoform disorders as disorders of affect regulation: a
development perspective. Int. Rev. Psychiatry 18 (1), 13–24.
WHO World Health Organization, 1992. ICD-10 Classification of Mental and
Behavioural Disorders, The: Clinical Descriptions and Diagnostic Guidelines. World
Health Organization.
Wiborg, J.F., Gieseler, D., Fabisch, A.B., Voigt, K., Lautenbach, A., Löwe, B., 2013a.
Suicidality in primary care patients with somatoform disorders. Psychosom. Med. 75
(9), 800–806.
Wiborg, J.F., Gieseler, D., Löwe, B., 2013b. Suicidal ideation in German primary care.
Gen. Hosp. Psychiatry 35 (4), 366–369.
Woodruff, R.A., Clayton, P.J., Guze, S.B., 1972. Suicide attempts and psychiatric
diagnosis. Dis. Nerv. Syst. 33 (9), 617–621.