Wits Vuvuzela journalist Hazel Meda addresses the issue of depression and somatoform disorder in her first feature.
Thembi* slammed her fist onto her friend’s kitchen counter.
“I am not depressed! I’m sick!” she shouted.
She pointed at the small yellow packet of pills which lay next to Hlengiwe’s laptop.
“He didn’t even spend five minutes with me and he’s giving me anti-depressants,” she said, her voice dripping with contempt.
She was fuming, because she had searched for the name “amitryptiline” on Google and discovered that the pills Dr Jones had given her were in fact a powerful anti-depressant.
Thembi had always avoided consulting the doctor, because she thought he was useless. But he had been the doctor on call at the surgery in Mbabane that Saturday afternoon when she felt so dizzy she thought she’d die.
Thembi may have doubted the doctor’s competence back then, but today she is grateful to him for setting in motion the process that would eventually get her the help she had been seeking for almost a year.
Thembi had never heard of somatoform disorder, but she was relieved to know that what she’d been feeling actually had a name. She wasn’t crazy and she hadn’t been making it all up to get attention.
A week later, Thembi was sitting in the office of Swaziland’s only psychiatrist, Dr Walter Mangezi. He handed her the green National Psychiatric Centre outpatient card which she had filled out an hour earlier.
“Major depression and somatoform disorder” he had scrawled.
Thembi had never heard of somatoform disorder, but she was relieved to know that what she’d been feeling actually had a name. She wasn’t crazy and she hadn’t been making it all up to get attention. She thanked Dr Mangezi for putting an end to her long and costly search for a diagnosis.
According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders, or DSM, several conditions fall into the category of somatoform disorders. They include undifferentiated somatoform disorder, pain disorder, hypochondriasis and body dysmorphic disorder.
What they have in common is that patients complain of symptoms which don’t have a medical explanation, but which are also not intentionally made up. It is thought that these disorders are physical manifestations of emotional distress.
About 60% of patients who are seen in clinics are actually suffering from a somatoform disorder
Dr Werdie van Staden, a professor of psychiatry at the University of Pretoria and the Editor in Chief of the South African Journal of Psychiatry, says he has treated many patients with somatoform disorders for about 20 years.
Van Staden says there is no reliable data on somatoform disorders in South Africa. He says it is difficult to determine the prevalence of these conditions, because patients often present to general practitioners rather than to psychiatrists and are often not diagnosed in these terms.
Dr Mangezi told Thembi that about 60% of patients who are seen in clinics are actually suffering from a somatoform disorder. A 2007 paper by Dr Kurt Kroeneke of the Indiana School of Medicine says 10 to 15% of patients seen in a primary care (general practitioner) setting in the United States have the condition. Kroeneke says the condition “leads to excessive healthcare use, costing the US healthcare system an estimated $100 billion annually”.
Thembi first went to her general practitioner complaining of severe pain in her left breast
Kerri Alexander, a psychologist at the Wits Counselling and Career Development Unit, says it takes a long time before patients eventually end up in the office of a mental health practitioner.
“Generally, clients will initially be seen at a hospital or health clinic, and are then usually referred for neurological tests etc.” Alexander says.
“Only once all of the possible medical conditions have been ruled out do they then think it might be psychological.”
Thembi incurred thousands of rands in unnecessary medical expenses as her doctors went through their process of elimination. She was lucky that her employer offered a very good medical aid scheme which paid most of her bills, but she still spent a lot of money out of pocket.
Thembi first went to her general practitioner complaining of severe pain in her left breast. When the pain persisted despite strong painkillers, he ordered a mammogram to rule out breast cancer.
She read about a deadly new type of breast cancer which occurred in young black women
At the time, the only mammogram machine in Swaziland was broken and Thembi had to travel to a specialist breast care clinic in South Africa. The mammogram was clear, but Thembi was still worried. While visiting relatives in Texas, she read about a deadly new type of breast cancer which occurred in young black women and which couldn’t be detected easily by mammograms because it occurred in sheets, rather than lumps. She insisted on another mammogram, which she paid for out of pocket. Again, the radiologist found nothing.
Back in Swaziland, Thembi visited her doctor repeatedly to discuss the breast pain and the other symptoms she had developed – shooting pain in her legs and arms, a foggy brain, slow thinking, serious forgetfulness, dizziness which prevented her from driving, and palpitations. The doctors ordered a CAT scan, which came back clear. Thembi didn’t know whether to be happy or sad.
Besides trying to cope with the symptoms, she also had to try to hide her problems from her employer, since she was afraid of losing her job.
According to the DSM, for undifferentiated somatoform disorder to be diagnosed, “the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
Van Staden says the disorder varies in severity, but that it can be “very debilitating in all aspects of daily functioning.”
She felt she was dying and nobody could help her
Thembi struggled to get through her work day. She was so dizzy that she couldn’t stand and had to teach her English classes while sitting on top of the desk and leaning against the blackboard. She felt exhausted and groggy all the time. She couldn’t remember the students’ names and made spelling mistakes on the board, something she had never done before.
She monitored her symptoms obsessively. She felt she was dying and nobody could help her. Her persistent symptoms, her doctors’ failure to find a solution and her inability to do her work drove her into depression.
Somatoform disorder seems to be associated with anxiety and depression, but researchers Roselind Lieb, Gunther Meinlschmidt and Ricardo Araya say no one can tell whether the disorder causes depression or vice versa.
Perhaps because of this link, anti-depressants are often used in the treatment of somatoform disorder.
According to Van Staden, there is no medicine that works specifically for somatoform disorders, although some medicines show promise for the treatment of body dysmorphic disorder and pain disorder. However, he says anxiety and depression generally respond well to medication.
“Treatment of these concomitant conditions often helps and even cures the somatoform symptoms,” he says.
Amitryptiline worsened the switched-off, foggy-brain feeling Thembi had and Dr Mangezi put her on another drug in the same family, fluoxetine, commonly known as Prozac.
He also advised her to see a psychologist.
Alexander says talk therapies “may help in getting the client to express the emotional pain and in this way relieve the physically displaced pain”.
Thembi isn’t sure that the talk therapy helped her, because she didn’t discuss much with the psychologist.
“She just used to ask me how I was feeling that week and encourage me to persevere with the medication even though I wasn’t seeing results quickly.”
After a few months on the medication, Thembi realised one day that she no longer had the breast pain or the shooting pains in her limbs. Her mind felt clearer and she was no longer felt so dizzy. Her palpitations had stopped and she was no longer anxious about her health. Maybe she wouldn’t die after all.
*The names of the patient, her friend and her general practitioner have been changed to protect their identities.