Conceptualizations of dissociation and somatization in literature on chronic pelvic pain in women: A scoping review

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EJTD-93; No. of Pages 11 European Journal of Trauma & Dissociation xxx (2018) xxx–xxx

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Research Paper

Conceptualizations of dissociation and somatization in literature on chronic pelvic pain in women: A scoping review Lisa S. Panisch Steve Hicks School of Social Work, University of Texas at Austin, 1925 San Jacinto boulevard, Stop D3500, 78712 Austin, TX, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 25 November 2018 Received in revised form 1st January 2019 Accepted 1st January 2019 Available online xxx

Introduction. – A history of trauma and related symptoms, notably dissociation, are prevalent among women with chronic pelvic pain (CPP). High levels of comorbidity exist between CPP and psychiatric conditions associated with trauma. While CPP requires the expenditure of substantial medical resources, it is often considered treatment-resistant, particularly in cases with high levels of comorbidity. Dissociation, a common symptom of trauma, has been linked to numerous adverse physical and mental health outcomes. However, research on dissociation is hindered by conceptual unclarity surrounding the term. Conceptual issues include concerns over the emphasis on psychological over somatoform dissociation and the subsequent failure of modern diagnostic systems to consider potentially dissociative nature of some somatization disorders. Objective. – The purpose of this scoping review was to gain insight into how dissociation and somatization are conceptualized in the peer-reviewed literature on women with traumatic histories who were diagnosed with CPP. Method. – All qualitative and quantitative peer-reviewed studies providing outcome data for women diagnosed with CPP who have a history of trauma published between 1980 - March, 2018 were included. Nine articles met inclusion criteria. Results. – Three studies explicitly conceptualized dissociation, and only two of these assessed patients for psychological and somatoform dissociation. Five studies measured somatization without considering the role of dissociation. Conclusion. – This study reveals that conceptual unclarity regarding dissociation and somatization exists in the peer-reviewed literature on traumatized women with CPP. A recommended protocol meant to enhance conceptual clarity is provided for future authors.

C 2019 Elsevier Masson SAS. All rights reserved.

Keywords: Chronic pelvic pain Dissociation Somatoform dissociation Somatization Sexual abuse Women’s health

1. Introduction Chronic pelvic pain (CPP) is a prevalent health issue among women that comprises a substantial amount of help-seeking behavior in gynecology clinics and secondary care settings (Howard, 1993; Zondervan et al., 1999). The etiology of CPP is unclear; the condition has been linked to numerous risk factors, with a history of traumatic experiences being salient among them (Latthe, Mignini, Gray, Hills, & Khan, 2006; Meltzer-Brody & Leserman, 2011; Meltzer-Brody et al., 2007). Among women with CPP who have a history of trauma, the role of dissociation warrants notable attention, as researchers have found connections between dissociation and negative mental and physical health outcomes both in general and clinical populations, as well as in specific

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relation to patients with CPP (Badura, Reiter, Altmaier, Rhomberg, & Elas, 1997; Gupta, Vujcic, & Gupta, 2017; Kendall-Tackett & Klest, 2009; LaChapelle & Hadjistavropoulos, 2004; Nijenhuis et al., 2003; Walker & Katon, 1992). Dissociation is a common symptom of trauma (Lanius, 2015; Powers, Cross, Fani, & Bradley, 2015; Schimmenti A & Caretti, 2016). It is recognized in the fifth edition of the Diagnostic and Statistical Manual (DSM-V) of the American Psychiatric Association (APA) under the category of dissociative disorders (American Psychiatric Association, 2013). According to the DSM-V, dissociation is comprised of symptoms including feelings of detachment and/or being outside one’s body (depersonalization and derealization), memory loss (dissociative amnesia), and, in cases of dissociative identity disorder, the existence of two or more distinct personality states or identities (American Psychiatric Association, 2013). Some dissociative symptoms also characterize a distinct sub-type of post-traumatic stress disorder (PTSD; American Psychiatric Association, 2013).

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The DSM’s conceptualization of dissociation in current and previous editions has been critiqued by some researchers, notably for its focus on primarily psychological symptoms and exclusion of somatoform symptoms (Nijenhuis, 2009; Van der Hart & Dorahy, 2009; Van der Hart, Nijenhuis, Steele, & Brown, 2004). The DSM-V has classified all symptoms of a somatoform nature without a clear medical origin into their criteria for somatic symptoms and related disorders (American Psychiatric Association, 2013); this category was previously known as somatoform disorders in the DSM-IV (American Psychiatric Association, 1994). However, this classification fails to account for the potentially dissociative nature of somatoform symptoms, a possibility underscored by study results which reveal that a considerable number of patients with dissociative disorders could also be diagnosed with conversion or other somatoform disorders (Brown, Schrag, & Trimble, 2005; Espirito-Santo & Pio-Abreu, 2009). Disagreement and confusion surrounding diagnostic criteria for dissociation is reflective of the general unclarity surrounding the concept of dissociation among researchers. Although modern diagnostic language focuses primarily on psychological symptoms of dissociation, historically, this was not always the dominant emphasis. Early pioneering work during the late 1800s by French researcher Pierre Janet viewed the psyche and soma as an integrated unit; Janet did not distinguish between psychological and somatoform symptoms of dissociation (Nijenhuis, 2009). However, the work of Janet’s fellow French researcher, Pierre Briquet, would serve as an augury for the later distinctions between somatoform versus psychological symptoms of dissociation that have muddied a contemporary conceptual understanding of dissociation (Mai & Merskey, 1980; Nijenhuis, 2009; Van der Hart et al., 2004). In opposition to the modern emphasis on psychological dissociation, Briquet’s work focused on somatoform phenomenon; Janet’s contemporary was in fact the namesake of Briquet’s syndrome, a type of hysteria that focused on somatoform phenomena. In Briquet’s 1859 writings (Nijenhuis, 2009), he noted that a high degree of amnesia could be observed among patients with somatoform manifestations of hysteria. This has been corroborated by modern results, such as those of Brown et al. (2005), who found significantly higher levels of dissociative amnesia among patients with somatoform symptoms. Somatoform dissociation was historically recognized in World War I veterans (Van der Hart, van Dijke, van Son, & Steele, 2000), and more recently among patients with eating disorders, borderline personality disorder, and other forms of psychopathology (Sar, Akyu¨z, Kundakc¸i, Kiziltan, & Dog˘an, 2004; Waller et al., 2003). Of note, studies have also identified somatoform dissociation among women with female sexual dysfunctions (Farina, Mazzotti, Pasquini, & Giuseppina Mantione, 2011), and both psychological and somatoform dissociation in women with CPP (Nijenhuis et al., 2003). The split between psychological and somatoform dissociative symptoms in the DSM deviates from the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD) criteria for dissociative disorders, which acknowledges somatoform symptoms related to absence, or negative dissociative symptoms, such as analgesia (World Health Organization, 1992). This is congruent with the historical perspective of Gilles de la Tourette, whose 1887 work (Van der Hart & Dorahy, 2009) stated that sensory awareness can be split from consciousness and experienced as a sensory absence, as observed in hysterical symptoms such as analgesia, medically unexplained blindness, etc. Nonetheless, both the DSM and ICD have been critiqued for excluding positive somatoform dissociative symptoms, such as sexual dysfunction and localized pain, in their diagnostic criteria (Nijenhuis, 2009, Van der Hart et al., 2004). Nijenhuis (2009) asserts that symptoms of this nature may be associated with non-integrated traumatic memories of a sensori-

motor affective nature, such as a visceral memory of rape or sexual abuse. This is of particular concern regarding CPP, as traumatic experiences of a sexual nature have been reported by a large number of women with this condition (Beck, Elzevier, Pelger, Putter, & Voorham-van der Zalm, 2009; Cichowski, Dunivan, Komesu, & Rogers, 2013; Mark, Bitzker, Klapp, & Rauchfuss, 2008; Poleshuck et al., 2005). Attempts to treat CPP require substantial expenditure of medical resources (Zondervan et al., 1999). Yet, the unclear etiology of CPP remains unclear, perhaps due to the many factors that could potentially contribute to its development. The role of trauma, and specifically dissociation, may be a fruitful area of focus to pursue, particularly in light of emerging neurobiological discoveries. As a harbinger of neuroscience research that would be revealed well over a century in the future, Pierre Briquet posited that somatoform dissociative symptoms could be partially attributed to areas of the brain responsible for processing affect (Micale, 2009). In addition, studies have found that traumatic experiences may contribute to neuroendocrine and immunological processes that underlie general chronic pain syndromes (Elenkov & Chrousos, 2006; Gill, Saligan, Woods, & Page, 2009) and, specifically, CPP (Heim, Ehlert, Hanker, & Hellhammer, 1998; Mayson & Teichman, 2009). Due to the high prevalence of adverse experiences found among women with CPP, a trauma-informed approach to treatment has been recommended (Rosenbaum, 2009). Findings from studies using trauma-specific interventions for mental health-related conditions support this (Kluetsch et al., 2014; Nicholson et al., 2017; Van der Kolk et al., 2007). These results are notable in light of research indicating that CPP in women is considered to be intractable in cases with high rates of comorbidity (Howard, 2003). CPP is known to be comorbid with several gynecological syndromes and multiple psychiatric conditions, many of them also associated with a history of trauma, such as depression and anxiety (Chen et al., 2010; Meltzer-Brody et al., 2007; Mayson & Teichman, 2009; Meltzer-Brody & Leserman, 2011; Reed et al., 2000; Wilson, 2010). Because trauma-related symptoms like dissociation are connected with numerous adverse physical and mental health outcomes (Badura et al., 1997; Gupta et al., 2017; Kendall-Tackett & Klest, 2009; LaChapelle & Hadjistavropoulos, 2004; Nijenhuis et al., 2003; Fisher, Robert, Jarrell, Carlson, & Taenzer, 2004; Walker & Katon, 1992), it is feasible that the alleviation of dissociation and related effects of trauma may provide simultaneous relief from CPP symptoms. However, a recent review of the intervention literature for CPP failed to identify any interventions with a trauma-specific focus (Panisch & Tam, 2019), and concluded by urging researchers to pursue further inquiry and treatment developments in this area. To be successful, a clear and consistent understanding of dissociation is necessary for the development of effective treatments with a targeted focus on the role of trauma and dissociation in women with CPP. To date, there have been no studies on how dissociation is conceptualized in the peer-reviewed literature on women with CPP. The purpose of this study was to answer pursue that inquiry. To ensure a thorough understanding, historical connections between somatoform and psychological dissociation, coupled with the modern diagnostic separation of dissociative disorders from those of a somatic nature (referred to heretoforth as ‘‘somatization,’’ to broadly reflect the language used in the DSM-V) must be considered. Therefore, this study sought to gain insight into how dissociation and somatization are conceptualized in the peerreviewed literature on women with traumatic histories who were diagnosed with CPP. 2. Methods Our primary research question was to investigate how dissociation and somatization were conceptually defined in the

Please cite this article in press as: Panisch, L. S. Conceptualizations of dissociation and somatization in literature on chronic pelvic pain in women: A scoping review. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/j.ejtd.2019.01.001

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peer-reviewed literature on CPP in women who had experienced trauma. To answer this, a scoping review was selected as the methodological approach in this study. As opposed to a focus on study outcomes and treatment effectiveness, a scoping review can be utilized to ‘‘identify gaps in the existing literature: this type of scoping study takes the process of dissemination one step further by drawing conclusions from existing literature regarding the overall state of research activity’’ (Arksey & O’Malley, 2005, p. 21). Advice from a librarian at a large, public, research-intensive university was solicited to create the following search string: (‘‘chronic pelvic pain’’ OR CPP) AND (dissociati* OR derealization OR depersonalization) AND (‘‘child* abuse’’ OR ‘‘sex* abuse’’ OR rape OR ‘‘child* sex* abuse’’ OR ‘‘sex* assault’’ OR ‘‘sex* trauma’’ or ‘‘child* trauma’’ OR ‘‘early trauma’’ OR ‘‘early life trauma’’ OR ‘‘early life stress’’ OR ‘‘child* advers*’’ OR ‘‘adverse childhood experiences’’ OR ‘‘child* maltreatment’’). On March 11, 2018, this search string was used to identify relevant articles from PsycINFO, CINAHL Plus with Full Text, MEDLINE, all contained in the university’s EBSCOhost platform. The same string was used to search PubMed as well. The search was limited to articles in academic journals written in English. Articles could be of a qualitative or quantitative nature and were included if they included outcome results, and if the primary population studied was women with a primary diagnosis of CPP who had experienced trauma. Traumatic experiences were defined as resulting: from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. Substance Abuse and Mental Health Services Administration, 2012, p. 271 Exclusion criteria based on methodology included case studies, reviews, and conceptual articles. Articles were also excluded if they were written before 1980, as this was the year that dissociative disorders were first explicitly defined in the publication of the new DSM III (Van der Hart & Dorahy, 2009). The publication of the DSM III in 1980 is also notable as it represents the time that somatoform manifestations of dissociation were separated from other dissociative phenomena and regrouped under the category of Somatoform Disorders. This new category included additional symptoms unrelated to dissociation, thereby contributing to the conceptual unclarity that persists to this day (Van der Hart & Dorahy, 2009). Studies were excluded from the title/abstract review if they did not mention dissociation, somatization (or a related term, such as conversion or somatoform), or trauma, or if they failed to meet other inclusion criteria. Studies that did not measure either dissociation or somatization in the full text were excluded from the review. Other than gender of the treatment group with CPP, no exclusion criteria was specified in regard to the demographic characteristics of participants, nor the presence of comorbid health conditions.

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chart, collate, and summarize the results of data in a scoping review, two tables were developed in Microsoft Word. The first table records the name of the first author and year the article was published, along with the country that the study was located, and the methodological design. Characteristics of the sample and study (i.e., sample size, gender, and a summary of findings) were also noted, and are described further below and also found in Table 1. The studies were then analyzed further to obtain information about additional mental health conditions measured, specific types of trauma experienced by participants, and measurement instruments used, as described below in the Results section and outlined in Table 2. To answer the primary research inquiry, articles were assessed for answers to the following series of additional questions:  was dissociation explicitly mentioned?  If mentioned, was dissociation explicitly defined or conceptualized? If so, how?  Was somatization explicitly mentioned?  Was somatization explicitly defined or conceptualized? If so, how?  Did the authors acknowledge any conceptual unclarity regarding dissociation or somatization, either as separate concepts or in relation to each other? The conceptual analysis was conducted by the author, with a content expert serving as a trustworthiness checkpoint (Arksey & O’Malley, 2005). The analysis utilized a three-phased approach. First, each article was first read in its entirety to gain conceptual understanding and ensure that inclusion criteria was met. Next, the articles were reviewed again, and all text related to the terms dissociation and somatization, including text providing information on their use in context, was copied and pasted into a Microsoft Excel database. The text in this database was then coded for answers to the series of conceptual questions listed above. In addition, the author made note of any novel, recurring themes that emerged from the extracted text. Results of the analysis are described below, and a summary can also be found in Table 2.

3. Results As demonstrated in Fig. 1, the search procedures were congruent with the reporting guidelines recommended by the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (Moher, Liberati, Tetzlaff, Altman, & Prisma Group, 2009). Combined, the search results from the databases on the EBSCOhost platform and PubMed yielded a total of 198 articles, after the removal of one duplicate article. After an initial screening of the titles and abstracts, it was determined that 185 of these articles did not meet the criteria for inclusion, leaving the full texts of 13 articles to be assessed. Of these, 4 articles were excluded; CPP was not the primary diagnosis of the participants in two articles, and neither dissociation nor somatization were measured in the full text of another two articles. The remaining nine studies were included in this review.

2.1. Analytic procedures 3.1. Sample characteristics From prior readings in this area, it is clear that there is a considerable amount of conceptual unclarity in regard to the term dissociation, and that this is further compounded when considering the concept of somatization, and the discrepancies between historical and modern understandings of the relationship between the two concepts (Nijenhuis, 2009; Nijenhuis & Van der Hart, 1999; Van der Hart & Dorahy, 2009; Van der Hart et al., 2004). Following procedures recommended by Arksey and O’Malley (2005) meant to

The number of female participants across all studies combined was 807. When considering each study individually, the smallest overall sample size was 40 (Ehlert, Heim, & Hellhammer, 1999), and the largest sample consisted of 220 females (Spinhoven et al., 2004). Sample participants in all but one study (Spinhoven et al., 2004) were 100% female. The study by Spinhoven and colleagues contained four subgroups: 1) 100% female patients with CPP, 2)

Please cite this article in press as: Panisch, L. S. Conceptualizations of dissociation and somatization in literature on chronic pelvic pain in women: A scoping review. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/j.ejtd.2019.01.001

Study location

Sample size

% female

Mean age (years)

Major findings

Badura et al., 1997

Quantitative, nonexperimental

United States

n = 46

100

30.98

Ehlert et al., 1999

Quantitative, nonexperimental

Germany

100

Overall = 28.93: n1 = 27.9; n2 = 28.8; n3 = 30.1

Nijenhuis et al., 2003

Quantitative, nonexperimental

Netherlands

n = 40: n1 = 16 (idiopathic CPP [ICCP]); n2 = 10 (CPP + abdominal adhesions [ACCP]); n3 = 14 (infertile controls, no pain) n = 52

Compared to women without a history of abuse, abused women had significantly higher mean rank scores on measures of dissociation, somatization, and substance abuse. Significant associations were revealed between dissociation and somatization, substance abuse, and maladaptive coping, in addition to correlations between somatization and substance abuse, as well as maladaptive coping In comparison to the control group, significantly higher rates of sexual abuse were found among women with ICCP, as were higher scores on somatization measures for both the ICCP and ACCP groups

100

38.7

Oso´rio et al., 2016

Quantitative, nonexperimental

Brazil

n = 100: n1 = 50 (with CPP); n2 = 50 (without CPP)

100

Reiter et al., 1991

Quantitative, nonexperimental

United States

n = 99: n1 = 47 (somatic CPP); n2 = 52 (non-somatic CPP)

100

Overall = 37.67: n1 = 37.44; n2 = 37.9 Overall = 28.65: n1 = 30.0; n2 = 27.3

Spinhoven et al., 2004

Quantitative, nonexperimental

Netherlands

n1 = 100; n2 = 77; n3 = 74.5; n4 = 83.3

Overall = 36.5: n1 = 37.8; n2 = 31.5; n3 = 39.1; n4 = 37.6

Walker et al., 1992

Quantitative, nonexperimental

United States

100

Overall = 29.4: n1 = 27.6; n2 = 31.2

Walker et al., 1988

Quantitative, nonexperimental

United States

n = 269: n1 = 52 (female patients with chronic pelvic pain; n2 = 61 (patients with non-epileptic seizures/ female = 47); n3 = 102 (patients with motor or sensory type conversion disorders/female = 76); n4 = 54 (a second sample of patients with predominantly motor or sensory types of conversion disorder/female = 45) n = 43: n1 = 22 (lifetime history of CPP); n2 = 21 (never had CPP) n = 55: n1 = 25 (CPP); n2 = 35 (specific gynecological conditions)

100

Not provided

Walling et al., 1994

Quantitative, nonexperimental

United States

n = 152: n1 = 64 (CPP); n2 = 42 (chronic headache) n3 = 46 (no chronic pain)

100

Overall = 29.71; n1 = 29.44; n2 = 29.98

Positive correlations were found in relation to somatoform dissociation and both psychological dissociation and DSM-IV symptoms of dissociative disorders. Greater severity of traumatic experiences was positively related to greater levels of psychological and somatoform dissociation, with stronger associations found between somatoform dissociation and trauma severity than psychological dissociation and trauma severity. Physical abuse/life threat was the strongest predictor of somatoform and psychological dissociation Compared to members of the control group, CPP patients were found to have a higher prevalence of both somatization and hypochondria, although a significant difference between the CPP and control group was only found among those with hypochondria Mean scores on measures of somatization were found to be significantly higher for women with non-somatic than for those with somatic CPP. The prevalence of sexual trauma prior to age 20 was significantly higher among women with non-somatic CPP than among those with somatic CPP Abuse history did not account for a significant amount of the variance in the relationship between psychological dissociation and CPP or conversion disorders. Based on results of semi-partial correlations, physical abuse, but not sexual abuse, was found to account for a small to moderate amount of the variance in the relationship between somatoform dissociation among women with CPP and patients with conversion disorder while controlling for level of psychopathology

When compared to women without CPP, those with CPP were found to score higher on measures of dissociation, somatization, and psychosocial distress, to have worse perceptions of mental health, and a greater prevalence of childhood sexual abuse When compared with the control group, women with CPP had a significantly greater prevalence of lifetime and current major depressive disorders, lifetime drug dependence or abuse, histories of childhood and adult sexual abuse, as well as higher scores on measures of somatization. Significant relationships were found between CPP and lifetime depression in women with a history of childhood sexual abuse, but not among women who were not sexually abused as children Significant relationships were found between somatization and CPP, and somatization and childhood sexual and physical abuse. Somatization was significantly predicted by a history of childhood physical abuse

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Study methodology

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Author and year

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Table 1 Summary of study and participant characteristics.

Trauma specified

Psychiatric conditions measured (other than dissociation or somatization)

Measures

Conceptualizations of dissociation and somatization

Badura et al., 1997

Childhood sexual abuse; childhood physical abuse; adult sexual abuse; adult physical abuse

Substance abuse

DES (dissociation); a structured clinical interview (trauma history and somatization; Reiter & Gambone, 1990); COPE scale (substance abuse and coping styles)

Ehlert et al., 1999

Childhood sexual abuse; childhood physical abuse; recent major life events not associated with physical or sexual abuse

Depressive mood, general mental health

Nijenhuis et al., 2003

Sexual harassment and sexual abuse (any age), physical abuse (any age), emotional abuse (any age), emotional neglect (any age), other types of trauma not related to abuse or neglect (any age)

Anxiety, depression

SOMS (German screening for somatoform symptoms); Mehrdimensionale Schmerzskala (MSS; German measure for subjective ratings of pain); Self-Rating Depression Scale (depressive mood); Diagnostic Interview for the DSM III (general mental health) Sexual Abuse Interview (childhood sexual abuse); Sexual and Physical Abuse Questionnaire (childhood sexual and physical abuse); a structured interview (recent major life events) DES (dissociation); SDQ-20 and SDQ-5 (somatoform dissociation); TEC (trauma history); SCID-D (dissociative disorders); STSD (somatization disorder); HADS (anxiety and depression)

Dissociation was explicitly mentioned; dissociation was not explicitly conceptualized; dissociation was conceptualized solely by the measurement instrument used in the study; somatization was explicitly mentioned; somatization was not explicitly conceptualized; somatization was conceptualized solely by the measurement instruments used in the study Dissociation was not explicitly mentioned or conceptualized; somatization was explicitly mentioned; somatization was explicitly conceptualized; conceptual unclarity surrounding the somatoform disorders and its various sub-categories was acknowledged

Oso´rio et al., 2016

Childhood sexual abuse, childhood physical abuse, childhood emotional abuse, childhood general trauma

Mood disorders (depression, bipolar, dysthymia), substance abuse/dependence disorders, PTSD, anxiety disorders (general, panic, social, and phobic), eating disorders (anorexia and bulimia)

Reiter et al., 1991

Childhood sexual abuse

SCID-I/CV (Axis I mental health disorders); ETISR-SF (Brazilian version; trauma history prior to age 18)

A structured clinical interview (somatic and emotional symptoms unrelated to pelvic or abdominal pain; Reiter & Gambone, 1990); a comprehensive medical and historical interview (medical conditions, pain, sexual history and sexual abuse history); a standardized medical evaluation (described in Hogston, 1987)

Dissociation was explicitly mentioned; psychological and somatoform dissociation were differentiated; somatoform dissociation was explicitly conceptualized; psychological dissociation was not explicitly conceptualized; psychological dissociation was conceptualized solely by the measurement instruments used in the study (and diagnostic criteria of the DSM and ICD); somatization was explicitly mentioned; somatization was not explicitly conceptualized; somatization was conceptualized solely by the measurement instruments used in the study; conceptual unclarity between somatoform dissociation and somatization was acknowledged Dissociation was not explicitly mentioned or conceptualized; somatization was explicitly mentioned; somatization was not explicitly conceptualized; somatization was conceptualized solely by the measurement instruments used in the study Dissociation was not explicitly mentioned or conceptualized; somatization was explicitly mentioned; somatization was explicitly conceptualized

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Author and year

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Table 2 Summary of specific trauma experiences, comorbid psychiatric conditions, measures, and conceptualization of dissociation in the studies.

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Psychiatric conditions measured (other than dissociation or somatization)

Measures

Conceptualizations of dissociation and somatization

Spinhoven et al., 2004

Childhood sexual abuse, adult sexual abuse, childhood physical abuse, adult physical abuse, emotional abuse or neglect (any age), general trauma not related to abuse or neglect (any age)

General psychopathology, affective complaints

DES (psychological dissociation); DIS-Q (pathological dissociation and trauma history); SDQ-20 (somatoform dissociation); STI (trauma history prior to age 16); TEC; SCL-90 (general psychopathology); HADS (affective complaints)

Walker et al., 1992

Childhood sexual abuse

General mental health and psychosocial distress

Walker et al., 1988

Childhood and adult sexual abuse

Walling et al., 1994

Childhood sexual abuse, childhood physical abuse, adult sexual abuse, adult physical abuse

General psychopathology and global distress, depression, phobias, panic disorder, substance dependence and abuse, functional dyspareunia, inhibited orgasm, inhibited sexual desire, inhibited sexual excitement Depression, anxiety

DES (dissociation); unnamed, structured sexual assault interview (childhood sexual abuse severity); GHQ (psychosocial distress); MOS (health perception, physical function, role function, social function, mental health), Barsky Amplification Scale (somatization) NIMH DIS (psychiatric diagnoses); Family History Research Diagnostic Criteria (family history); a structured interview (history of sexual abuse; Russell, 1986); SCL-90 (general psychopathology and global distress) A structured interview (physical and sexual abuse; based on the format described in Russell, 1983); SCL-90-R (depression and anxiety subscales); Wahler Physical Symptom Inventory (somatization)

Dissociation was explicitly mentioned; general dissociation was explicitly conceptualized; pychological and somatoform dissociation were differentiated; somatoform dissociation was explicitly conceptualized; Psychological dissociation was conceptualized solely by the measurement instruments used in the study; somatization was explicitly mentioned (by proxy - the term ‘‘somatoform disorders’’ seemed to be used in the place of somatization); somatization was not explicitly conceptualized; conceptual confusion between somatoform dissociation, conversion disorder, and somatoform disorders were acknowledged Dissociation was explicitly mentioned; dissociation was explicitly conceptualized; somatization was explicitly mentioned; somatization was conceptualized solely by the measurement instruments used in the study Dissociation was not explicitly mentioned or conceptualized; somatization was explicitly mentioned; somatization was conceptualized solely by the measurement instruments used in the study Dissociation was not explicitly mentioned, defined, or conceptualized; somatization was explicitly mentioned; somatization was conceptualized solely by the measurement instruments used in the study

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Trauma specified

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Author and year

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Table 2 (Continued )

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Fig. 1. Flow of information from identification to inclusion of studies.

male and female (77%) patients with non-epileptic seizures, 3) male and female (74.5%) patients with motor or sensory type conversion disorders, and 4) a second sample of male and female (83.3%) patients with motor or sensory type conversion disorders. The mean age of participants ranged from 28.65 (Reiter, Shakerin, Gambone, & Milburn, 1991) to 38.7 (Nijenhuis et al., 2003). One study (Walker et al., 1988) did not report age. Other demographic characteristics (i.e., race, ethnicity, employment) were not consistently reported across studies. Full details can be found in Table 1. 3.2. Study characteristics All studies used quantitative, non-experimental designs and were primarily of a prevalence nature. The most recent study (Oso´rio, Carvalho, Donadon, Moreno, & Polli-Neto, 2016) took place in 2016, and the earliest, conducted by Walker and colleagues, was conducted in 1988. The majority (56%, n = 5) of studies took place in the United States, two (22%) were conducted in the Netherlands, and the remaining two studies were conducted in Germany or Brazil. Additional details, including a summary of each study’s results, can be found in Table 1. Aside from dissociation and somatization, all but one study (Reiter et al., 1991) evaluated additional mental health concerns. These conditions, and instruments used to measure them are outlined in Table 2.

3.3. Evaluating trauma history Each study evaluated the participants for histories of specific types of traumatic experiences. A history of childhood sexual abuse was evaluated in all nine studies; two studies only assessed for childhood sexual abuse, while one study solely evaluated sexual abuse during both childhood and adulthood. Adult sexual abuse was assessed in five studies. Childhood physical abuse was assessed in six studies, while adult physical abuse was evaluated in four studies. Emotional abuse and/or neglect was evaluated in three studies; one focused on childhood experiences only, and the other two evaluated emotional abuse and/or neglect at any age. General trauma, other than abuse or neglect, was evaluated in four studies; of these, one focused only on childhood experiences of general trauma, one only on adult experiences, and the remaining two focused on experiences of general trauma at any age. Table 2 provides full details of specific traumatic experiences and tools used to assess them. 3.4. Measuring dissociation and somatization Several different measures were used to measure somatization and dissociation. In the reviewed studies, dissociation was measured by the following instruments: the Dissociative Experiences Scale (DES; Badura et al., 1997; Nijenhuis et al., 2003; Spinhoven et al., 2004; Walker & Katon, 1992), the full, 20-item

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version of the Somatoform Dissociation Questionnaire (SDQ-20; Nijenhuis et al., 2003; Spinhoven et al., 2004), the short form version of the SDQ (SDQ-5; Nijenhuis et al., 2003), the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D; Nijenhuis et al., 2003), and the DIS-Q (Spinhoven et al., 2004). Measures used to evaluate somatization included the Screening Test for Somatization Disorder (STSD; Nijenhuis et al., 2003), the Barsky Amplification Scale (Walker & Katon, 1992), the Wahler Physical Symptom Inventory (Walling et al., 1994), the SCL-90 (Walker et al., 1988), and the SCID-I/CV (Oso´rio et al., 2016). Somatization was also measured by Ehlert and colleagues (1999) by the SOMS, a German screening for somatoform symptoms. In addition, two studies used a structured clinical interview, outlined in Reiter and Gambone (1990) to assess for symptoms of somatization (Badura et al., 1997; Reiter et al., 1999). 3.5. Conceptualizations of dissociation and somatization The purpose of the conceptual analysis was to gain insight into how the concepts of dissociation and somatization are used in the peer-reviewed literature on traumatized women diagnosed with CPP. Designed to answer a series of specific questions listed in the Methods section, the analysis also sought to identify any novel and recurring themes that recurred among the text. Two such themes were identified: 1) when explicitly conceptualized or defined, distinctions were made between psychological and somatoform types of dissociative phenomena, and 2) dissociation and/or somatization were defined solely by the use of measurement instruments used in the study. While validated measurement tools indeed provide inherently explicit definitions of a concept, the degree to which the authors provided descriptive information about these measures varied, and clinicians treating CPP may not have the requisite expertise in measurement tools of dissociation or somatization to infer such definitions. Furthermore, clinicians in practice environments not affiliated with a university or other large research entity may have limited resources in terms of accessing these measures for further examination. Therefore, this latter theme was differentiated from other ‘‘explicit’’ conceptualizations or definitions of dissociation and somatization, in that the latter are explicitly stated in the text of the articles themselves. These themes are listed amongst our findings in Table 2 and will be incorporated into the synthesis below. 3.5.1. Defining dissociation Dissociation was explicitly mentioned in four studies. Of these, only one did not explicitly define or conceptualize dissociation aside from the use of a measurement instrument (Badura et al., 1997). Rather, dissociation was conceptualized solely by the DES. Walker and Katon (1992) provided the following explicit conceptualization of dissociation: ‘‘as defined by the DSM-R-III, dissociation is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness’’ (p. 534). Dissociation was mentioned in relation to forms of coping: ‘‘patients who have experienced childhood physical and sexual abuse have also been found to use dissociation as a coping mechanism. . .’’ (Walker & Katon, 1992, p. 534), and also posited as an adaptive defense to help individuals cope with traumatic experiences. The authors stated that dissociative ‘‘mechanisms may alter perceptions (derealization, depersonalization) and allow the person to forget (psychogenic amnesia) or even completely disown the experience as occurring in another person (multiple personality)’’ (Walker & Katon, 1992, p. 536). General dissociation was explicitly conceptualized by Spinhoven et al. (2004) as ‘‘the compartmentalization of traumatic experiences by which their impact is attenuated’’ (p. 306). Both Nijenhuis et al. (2003) and Spinhoven et al. (2004) differentiated

between psychological and somatoform types of dissociation, with Nijenhuis et al. explicitly defining the latter as ‘‘the partial or complete loss of the normal integration of somatoform components of experience, reactions, and functions. . . involves negative symptoms, such as anesthesia of various sensory modalities (for example, apparent disappearance of body parts, bodily numbing), analgesia and inhibited movement (e.g., stiffening of the body), as well as positive symptoms, such as site-specific pain (e.g., pain while urinating, pain in the genitals) uncontrolled movements and changing preferences of smells and tastes.’’ (2003, p. 88). Conceptual unclarity between somatoform dissociation and somatization was acknowledged by Nijenhuis and colleagues (2003). Likewise, in their definition of somatoform dissociation, Spinhoven et al. (2004) acknowledge similar conceptual unclarity regarding somatoform dissociation, conversion disorder, and somatoform disorders: dissociation also manifests in disturbances of sensation, movement, and other bodily functions. These disruptions–such as anesthesia, analgesia, sensory alterations, or loss of motor control–constitute the main symptom of conversion disorder and can be described as somatoform dissociation. . . some bodily dysfunctions of patients with particular somatoform disorders can be regarded as manifestations of somatoform dissociation’’ (p. 306). Meanwhile, Nijenhuis and colleagues (2003) based their conceptualizations of psychological dissociation was upon multiple measurement instruments (DES and SCID-D), along with diagnostic criteria from the DSM and ICD. The DES was used by Spinhoven et al. (2004) to conceptualize psychological dissociation. 3.5.2. Defining somatization Somatization, or a related term (e.g., medically unexplained somatic symptoms, somatoforms, somatization disorder, somatoform disorder) was explicitly mentioned in all nine studies reviewed. Reiter and colleagues (1991) explicitly conceptualized somatization as ‘‘high somatization (somatic symptom) scores and preoccupation with physical symptoms and concerns’’ (pp. 104105) that could be measured in women ‘‘without identifiable somatic pathology’’ (p. 105) or without ‘‘identifiable somatic abnormality’’ (p. 105) by a scale measuring the frequency of psychological and somatic symptoms ‘‘unrelated to pelvic or abdominal pain.’’ As such, they made distinctions between somatic and non-somatic CPP, based on laparoscopic results among their patients. However, they went on to critique the use of this approach for its lack of sensitivity and specificity. Somatoform disorders were conceptualized by Ehlert et al. (1999) as being ‘‘characterized by different, mostly persistent or recurrent complaints which are medically unexplained’’ (p. 87). These authors hypothesized that symptomology of somatoform disorders could apply to patients both with and without biological correlates for their conditions. Furthermore, conceptual unclarity surrounding the somatoform disorders and its various sub-categories was acknowledged (Ehlert et al., 1999). While Spinhoven et al. (2004) did not explicitly define or conceptualize somatization, he acknowledged the conceptual unclarity existing among terms like somatoform dissociation and conversion disorders, as previously described. Somatization was conceptualized solely by the measurement instruments used in three of the studies (Badura et al., 1997; Nijenhuis et al., 2003; Oso´rio et al., 2016; Walker & Katon, 1992;

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Walker et al., 1988; Walling et al., 1994). The primary conceptualization of somatization was represented by the associated measurement issues in three additional studies, although the authors of these studies provided further reflections on the phenomena of somatization (Walker & Katon, 1992; Walker et al., 1988; Walling et al., 1994). Somatization in reference to CPP was conceptually alluded to, along with general psychopathology, in the theoretical perspective that ‘‘psychological disturbance is a precipitant for the psychophysiological development of pelvic congestion’’ (Walker et al., 1988, p. 75). Likewise, Walling et al. (1994) asserted that the phenomena of somatization may have both medically identifiable and medically unexplainable origins. Although Walker and Katon (1992) did not explicitly mention somatoform dissociation, they provided a succinct conceptualization of somatization as it relates to dissociation, along with the associated implications for CPP:

presence of dissociation may alter a patient’s response to some treatments (Bae, Kim, & Park, 2016; Kleindienst et al., 2011; Resick, Suvak, Johnides, Mitchell, & Iverson, 2012). Dissociation can also serve as an indicator of severe psychiatric comorbidity (Sar et al., 2004). Therefore, the presence of dissociation is an important consideration for clinicians when developing a plan of intervention for their patients. As such, it is concerning that only two of the nine studies measured both somatoform and psychological dissociation. Likewise, whereas standard measures of somatization fail to ascertain whether symptoms are dissociative in nature, instruments like the SDQ-20 and SDQ-5 focus on somatoform symptoms that are highly correlated with dissociative phenomenon (Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996; Nijenhuis et al., 1997).

the high dissociation scores in this group of women with medically unexplained CPP may be the somatic representation of the severe physical and/or emotional traumatization that occurs secondary to childhood sexual, and, possibly, physical abuse. Thus, the patient with chronic pelvic pain may experience the pain as a partial ‘memory’ of the abuse without being consciously aware of the full extent of the memory (i.e., the physical, autonomic, and emotional traumatic memory of the abuse). (p. 536).

Several limitations should be considered when interpreting the results presented in this article. The methods used to search the literature may have failed to identify additional studies of relevance. In light of the acknowledged prevalence of abuse histories and trauma-related symptoms among women with CPP, it is surprising that only 9 studies met the criteria for inclusion in this review. Nonetheless, all attempts were made in consultation with a university reference librarian to ensure a rigorous approach was adhered to when searching the peer-reviewed literature. It is also possible that additional studies exist that are published in languages other than English. While inclusion criteria for this study specified articles written in English only, future inquiries of this nature could expand the inclusion criteria so that relevant studies in other languages could be analyzed. It is important to note that the presence of dissociation should not be assumed when a patient is diagnosed with a somatization disorder. Nonetheless, the use of tools like the SDQ is warranted to make these distinctions, particularly in populations like women with CPP, where a history of trauma and associated symptoms are prevalent.

4. Discussion CPP is a condition among women with that is associated with a history of traumatic experiences. However, to date, there are no treatment interventions for women with CPP that specifically address the role of trauma (Panisch & Tam, 2019). Symptoms of trauma, notably dissociation, have been observed in this population (Badura et al., 1997; Nijenhuis et al., 2003; Spinhoven et al., 2004; Walker & Katon, 1992). A thorough understanding of dissociation and related effects of trauma in women with CPP is necessary in the development of interventions meant to effectively treat these symptoms. However, as many researchers have lamented, there is a persistent lack of clarity surrounding the concept of dissociation, particularly regarding overlap between symptoms of somatoform dissociation and somatization, both associated with CPP (Nijenhuis et al., 2003; Oso´rio et al., 2016). This scoping review provides an overview of where the current literature on CPP stands regarding this conceptual issue. Our study has demonstrated that different conceptualizations of dissociation exist in the narrow sub-category of peer-reviewed literature on CPP in relation to trauma. Of further concern is that several studies failed to provide an explicit conceptualization of dissociation at all; rather, it appeared the reader was to assume to the meaning, which is troublesome in the context of widespread conceptual unclarity in research on trauma and dissociation. The majority of studies measured dissociation with either instruments that focused solely on psychological forms of dissociation, namely the DES, DIS-Q, and SCID-D (Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1997). However, some individuals with traumatic histories may be consciously unaware of their psychological dissociative symptoms (Nijenhuis et al., 1997). Instead, these individuals may instead be diagnosed with a somatization disorder, although the nature of this somatization could be attributable to dissociation. Without the proper identification of dissociation and other trauma-related symptoms, patients may be subject to ineffective interventions, resulting in wasted time, resources, and prolonged suffering. This is underscored by research findings which indicate that the

4.1. Limitations

4.2. Recommendations for future research These findings support the broader demand for conceptual clarity in regard to dissociation articulated by Nijenhuis (2009), by Nijenhuis and Van der Hart (2011), and by van der Hart and colleagues (2004). Nijenhuis (2009) provided specific suggestions to address the overlap between somatization and dissociation. First, he recommended the reclassification of somatization symptoms and disorders (e.g., conversion disorder) that are strongly correlated with dissociation into a new diagnostic category of dissociative disorders, namely somatoform dissociative disorders (Nijenhuis, 2009). The author of this study agrees that the category of somatoform dissociative disorders should be included in future editions of the DSM, and further asserts the need for the ICD-10 to acknowledge positive somatoform symptoms of dissociation, such as localized pain, that are relevant to CPP. This author also recognizes that the process for making changes to diagnostic criteria in the DSM and ICD span many years and require extensive resources. While such endeavors should nonetheless be pursued, this study has implications that can be addressed in a more immediate time frame. A basic set of standards is suggested for future researchers to adhere to when writing articles in this area. First, authors should always provide explicit definitions of dissociation and somatization. Authors should also provide a thorough description of the instruments selected to measure these constructs, and detailed explanations of the rationale underlying their selection. Overlap between modern conceptualization of somatization and dissociation should be acknowledged in the literature review. It is recommended that researchers measure somatization along with both psychological

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and somatoform dissociation among traumatized women with CPP, as results from these studies will provide deeper insight into the distinctions between them. These findings can be triangulated with physiological data measuring biological correlates, such as hormones and markers of inflammation, that are associated with trauma and chronic pain disorders (Elenkov, & Chrousos, 2006; Gill et al., 2009; Heim et al., 1998; Mayson & Teichman, 2009). If the results of these studies continue to demonstrate connections among trauma, dissociation, and CPP in women, the development of trauma-specific interventions targeting the role of dissociation should be pursued. 5. Conclusions Given the high prevalence of traumatic histories among women with CPP, it is important that clinicians understand relationships between dissociation and somatic symptoms. Unfortunately, this study shows that conceptual unclarity is persistent in this area. Definitions of dissociation and somatization varied among the studies reviewed and overlap between the two concepts were noted and differentiated in some, but not all, studies. There is a need for a clearly defined conceptualization of dissociation, particularly as it relates to somatization among researchers and clinicians treating traumatized women with CPP. Results of this study support the proposals of previous researchers to create a new diagnostic category, somatoform dissociative disorders, to help provide conceptual clarity. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Disclosure of interest The author declares that he has no competing interest. References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. Badura, A. S., Reiter, R. C., Altmaier, E. M., Rhomberg, A., & Elas, D. (1997). Dissociation, somatization, substance abuse, and coping in women with chronic pelvic pain. Obstetrics & Gynecology, 90(3), 405–410. Bae, H., Kim, D., & Park, Y. C. (2016). Dissociation predicts treatment response in eyemovement desensitization and reprocessing for posttraumatic stress disorder. Journal of Trauma & Dissociation, 17(1), 112–130. Beck, J. J., Elzevier, H. W., Pelger, R., Putter, H., & Voorham-van der Zalm, P. J. (2009). Multiple pelvic floor complaints are correlated with sexual abuse history. The Journal of Sexual Medicine, 6(1), 193–198. Brown, R. J., Schrag, A., & Trimble, M. R. (2005). Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder. American Journal of Psychiatry, 162(5), 899–905. Chen, L. P., Murad, M. H., Paras, M. L., Colbenson, K. M., Sattler, A. L., Goranson, E. N., & Zirakzadeh, A. (2010). Sexual abuse and lifetime diagnosis of psychiatric disorders: Systematic review and meta-analysis. Mayo Clinic Proceedings, 85(7), 618–629. Cichowski, S. B., Dunivan, G. C., Komesu, Y. M., & Rogers, R. G. (2013). Sexual abuse history and pelvic floor disorders in women. Southern Medical Journal, 106(12), 675–678. Ehlert, U., Heim, C., & Hellhammer, D. H. (1999). Chronic pelvic pain as a somatoform disorder. Psychotherapy and Psychosomatics, 68(2), 87–94. Elenkov, I. J., & Chrousos, G. P. (2006). Stress system – organization, physiology and immunoregulation. Neuroimmunomodulation, 13(6), 257–267. Espirito-Santo, H., & Pio-Abreu, J. L. (2009). Psychiatric symptoms and dissociation in conversion, somatization and dissociative disorders. Australian & New Zealand Journal of Psychiatry, 43(3), 270–276. Farina, B., Mazzotti, E., Pasquini, P., & Giuseppina Mantione, M. (2011). Somatoform and psychoform dissociation among women with orgasmic and sexual pain disorders. Journal of Trauma & Dissociation, 12(5), 526–534. Fisher, K., Robert, M., Jarrell, J., Carlson, L., & Taenzer, P. (2004). Other: Pain profiles of women with unexplained chronic vulvar pain: Implications for the classification, assessment, and diagnosis of women with vulvodynia. Journal of Pain, 5(3), S132.

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Please cite this article in press as: Panisch, L. S. Conceptualizations of dissociation and somatization in literature on chronic pelvic pain in women: A scoping review. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/j.ejtd.2019.01.001