Briquet's Syndrome (Hysteria) Is Both a Somatoform and a "Psychoform" Illness: A Minnesota Multiphasic Personality Inventory Study

RICHARD D. WETZEL, PHD, SAMUEL B. GUZE, MD, C. ROBERT CLONINGER, MD, RONALD L. MARTIN, MD, AND PAULA J. CLAYTON, MD

We describe the results of a follow-up study on patients with hysteria using the Minnesota Multiphasic Personality Inventory (MMPI) to evaluate the multiple complaints of these patients. MMPIs were obtained from 29 women with primary affective disorder and 37 women with Briquet's syndrome as part of a followup study of the St. Louis clinic 500. Patients with Briquet's syndrome were significantly less consistent and logical in answering MMPIs and were more likely to emphasize personal psychopathological conditions. They reported many more symptoms in many more problem areas than did women with primary affective disorder. Patients with Briquet's syndrome reported significantly more somatic symptoms and psychological/ interpersonal problems than did the depressed group. It was suggested that such patients mimic multiple psychiatric and somatic disorders. Key words: hysteria, affective disorder, somatization disorder, MMPI, somatoform, psychoform.

INTRODUCTION

Hysteria or Briquet's syndrome has typically been viewed, especially in recent decades, as a disorder with prominent physical symptoms that suggest or mimic a wide variety of medical conditions. At the same time, it was recognized early on that these conditions also include many psychological and emotional symptoms, including those usually associated with anxiety or mood disturbance. This article tests hypotheses about hysteria or Briquet's syndrome with regard to the parallel importance of emotional and psychological symptoms and the more widely recognized physical ones. The strategy used here is to compare the Minnesota Multiphasic Personality Inventory (MMPI) scale scores of patients with hysteria with the MMPI scores of other women with primary affective disorder (PAD). Briquet's syndrome (hysteria) is "a polysymptomatic disorder that begins early in life. .., chiefly affects women, and is characterized by recurrent, multiple somatic complaints often described dramatically" (1). Somatization disorder is the term for hysteria in Diagnostic and Statistical Manual o/Men-

From the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri (R.D.W., S.B.G., C.R.C.); Department of Psychiatry, University of Kansas School of Medicine-Wichita, Wichita, Kansas (R.L.M.); and Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota (P.J.C.). Address reprint requests to: Richard Wetzel, PhD, Department of Psychiatry, Washington University School of Medicine, 4940 Children's Place, St. Louis, MO 63110. Received for publication July 13, 1993; revision received January 14, 1994.

tal Disorders, 3rd edition revised (DSM-III-R) (2). However, the criteria in DSM-III-R differ from those for Briquet's syndrome, and the two diagnostic criteria select somewhat different but overlapping samples of patients (3). In a group of 123 women diagnosed with either somatization disorder or Briquet's syndrome, 63% met criteria for both disorders, 21% for somatization alone, and 16% for Briquet's syndrome alone. The MMPI is the most widely used clinical and research psychological test in psychology and psychiatry. Despite this fact, little has been reported concerning the performance of women with Briquet's syndrome on the MMPI except for two articles by Liskow et al. The first appeared in 1977 (4). They compared MMPI profiles from 21 patients they diagnosed as having Briquet's syndrome with the MMPI profiles of 29 hysteric patients reported by Slavney and McHugh (5). Slavney and McHugh diagnosed hysteria on the basis of psychological functioning. Both groups of patients showed virtually identical help-seeking or need-dramatizing tendencies, as shown by their scores on three validity (testtaking attitude) scales: L, F, and K (T scores of 54, 70, and 50: Briquet's; of 48, 70, and 52: hysteria). These scores indicate a willingness to report unusual symptoms. The 21 patients with Briquet's syndrome had, on average, seven MMPI scales (hypochondriasis, depression, hysteria, psychopathic deviant, paranoia, psychasthenia, and schizophrenia) of the standard 10 clinical scales with means of T scores that were 70 or higher (two or more standard deviations above the mean for normals). The mean scores for the 29 patients with hysteria were similar; six scores were over the T score of 70. This report suggested that the pathological condition in Bri-

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quet's syndrome is not limited to multiple medical complaints (somatoform); it also includes multiple psychological and interpersonal complaints (psychoform). The schizophrenia scale had the highest mean score of any standard clinical scale in both the Briquet's and hysteria groups. Liskow et al. (6) noted that 16 additional inpatients with Briquet's syndrome also had the same pattern of scores on the L, F, and K scales. Eight clinical scales of the 10 standard MMPI (8 clinical and 2 personality) scales were above 70. Schizophrenia was the highest scale score, with a mean of 88. This second report emphasized the frequent comorbidity associated with Briquet's syndrome, i.e., "female psychiatric patients with Briquet's syndrome invariably have several. .. additional psychiatric syndromes." They ".. . may simply report a great number of all types of psychiatric symptoms, just as they report a great number of all types of medical symptoms " (6, p. 466). Hundreds of MMPI scales exist (7). Because 5% of the MMPI scales examined could be significant as a result of chance alone, it is important to reduce the number of variables in a meaningful way. The usual way to solve this is to examine only the 10 standard scales. For some purposes, this is reasonable. However, the standard clinical scales are heterogeneous in content, which can make interpretation of findings problematic. Harris and Lingoes (8) divided six. of the clinical scales into face-valid content areas. For this study, we examined a set of MMPI scales and subscales that measured interpersonal problems and another set that measured somatic complaints or dysfunction. A control group of female psychiatric patients with PAD was used. This diagnosis defines a group of patients in whom a major depression developed be/ore any other Axis I psychiatric diagnosis (e.g., alcoholism or substance abuse). On the basis of the available reports on hysteria and clinical experience, a number of hypotheses about the MMPIs of patients with Briquet's syndrome were made as follows: 1. Women with Briquet's syndrome and with primary affective disorder have significantly different validity scale scores. A. Women with Briquet's syndrome are less accurate reporters. B. Women with Briquet's syndrome emphasize their disability and minimize their ability to cope. 2. Women with Briquet's syndrome report more psychiatric difficulties or psychoform problems (i.e., have significantly higher scores) on
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A. The Lachar-Wrobel critical item problem areas. B. The eight standard clinical scales (Hs, D, Hy, Pd, Pa, Pt, Sc, Ma). 3. Women with Briquet's syndrome have elevated scores on scales that assess interpersonal alienation and social problems and higher scores than women with PAD. 4. Patients with Briquet's syndrome show more somatoform symptoms by having higher scores on standard MMPI scales that reflect somatization than women with depression.

METHODS
The diagnosis of PAD was widely used (9-11) at Washington University to define a group of patients in whom a significant affective disorder developed before another psychiatric diagnosis (e.g., alcoholism or substance abuse). No restriction was placed on the number of psychiatric syndromes that might develop after the first affective syndrome occurs. The Washington University Clinic 500 study began in the years from 1967 to 1969. It assessed 500 patients from the psychiatry clinic with structured diagnostic interviews. After ascertainment of these probands, their first-degree relatives were interviewed blindly. From 1973 to 1979, extensive efforts were made to reinterview the patients in the Washington University clinic 500 study first interviewed in 1967 to 1969 (12-15). Four hundred twenty-two were found and interviewed in person (N = 348) or by phone (N = 74). MMPIs were obtained from 213 patients in the Washington University Psychiatry Clinic 500 population. Thirty MMPIs were excluded because of many missing answers (> 30) or excessive defensiveness (K > 70). Of the 324 women included in the clinic 500 studies, 153 (47%) were located during the 6- to 12-year follow-up and provided an MMPI. Women with Briquet's syndrome were significantly more likely to have returned an MMPI (40/68 or 59% vs. 113/256 or 44%, chi-square = 4.65, p < .05) than other psychiatric patients. Only three MMPIs from women with Briquet's syndrome were eliminated because of missing items or excessive defensiveness. Women with PAD were no more likely to return an MMPI than the average woman (37/76 or 49% vs. 116/248 or 47%, chi-square < 1). Eight of their MMPIs were not accepted. Analyses were done on T scores rather than raw scores unless otherwise indicated. Final diagnoses, the ones used in this study, were based on all available information (except the MMPIs) from the original evaluation, the follow-up interviews, and medical record reviews (12). Most of the patients ultimately considered to have definite or probable Briquet's syndrome were not initially diagnosed as such. The diagnostic criteria used were those of Feighner et al. (16). All statistical analyses were done using SAS software for personal computers (17, version 6.04).

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RESULTS

Validity Scale Scores The Q scale simply counts the number of unanswered or undecipherable items. The women with PAD omitted 10.7 such items on average; the women with Briquet's syndrome had 10.0 (t < 1, p = NS). Table 1 reports the means and standard deviations of a variety of validity scales. Consistency of Report. Two validity scales that assess pure carelessness are independent of the degree of psychopathology (18). One is the test-retest (TR) scale (19); the score represents disagreements with previous choices on 16 duplicate items on the 566 item MMPI. (The MMPI came in two versions at the time of follow-up: the 566 and the 550, which eliminated duplicates, with the result that the TR scale score could not be computed when the 550 form was used). Twenty-one of the women with PAD and 23 of those with Briquet's syndrome took the 566-item version. Women with Briquet's syndrome were significantly (t = 2.38, p < .05) more likely to change their answer to the identical question than were women with PAD. The carelessness scale (CLS) (20) uses 12 item pairs that are not duplicate items. Six pairs involve similar content and should be answered in the same way (> 90% of normals do), and six are opposite and should be answered in an opposite fashion (> 90% of normals do). Patients with Briquet's syndrome had higher scores (t = 2.17, p < .05), which indicated more carelessness or fewer logical answers to the MMPI. Greene (18) suggests the combination of the TR and CLS to assess the validity of a test. This could be done for only the 44 patients who took the 566-item version. This combination of the two scales showed significant differences between the two groups (t = 2.71, p < .01). Patients with Briquet's syndrome were less consistent and careful informants on the MMPI. Exaggeration of Distress. The F scale contains items infrequently endorsed by normals. Malingerers endorse more of these unusual items in the

scored direction than do psychotic patients. The K scale measures, in the middle ranges, the person's ability to cope with life and at higher levels, defensiveness. Subtraction of K from F indicates the balance between reporting pathological conditions and denying them. The patients with Briquet's syndrome scored higher than did the women with PAD on the F scale (t = 2.50, p < .05) and the F/K ratio (t = 2.39, p < .01). Both groups had means in the middle ranges on the K scale, although women with PAD reported significantly (t = 2.35, p < .05) better ability to cope than did patients, with Briquet's syndrome.

Complaints Multiple Psycho/orm Complaints. The LacharWrobel scales are a series of items that reflect complaints about psychological and somatic complaints. The list includes 111 items grouped into 11 different problem areas (21). Unlike most MMPI scales, there is no item overlap between these scales. Women with Briquet's syndrome endorsed a significantly greater total number of Lachar-Wrobel critical items (t = 5.21, p < .001) than did women with PAD (Table 2). The patients with Briquet's syndrome had significantly higher scores on 9 of the 11 Lachar-Wrobel scales (anxiety and tension, deviant beliefs, deviant thinking and experiences, depression and worry, family conflict, problematic anger, sexual deviation and concerns, sleep disturbance, and somatic symptoms). The number of items endorsed did not differ significantly on antisocial attitudes or substance abuse scales but were also slightly higher on these. Women with Briquet's syndrome reported more psychological pathological conditions in many areas. Elevated Scale Scores. Women with Briquet's syndrome had significantly more primed (T score > 70) scales than did women with PAD (3.46 2.65 vs. 1.24 1.84, t = 4.00, p < .001). They also had more double-primed (T score > 80) scales (1.27 1.54 vs.

TABLE 1. Validity Scales' by Diagnosis L PAD (N = 29) Briquet syndrome (N = 37) T 4.3 2 4 4.5 + 2.3 0.4 NS F 6.1 4.6 9.0 4.7 2.50* K 12.9 5.0 10.1 4.4 2.39* F/K -6.8 7.4 -1.1 6.9 3.21** TR" 1.7 1.7 2.9 1.7 2.38* CLS 1.9 1.2 2 7 1.6 2.26* TR+CLS^. 3.6+ 1.9 5.7 3.0 2.72**

' N for PAF, 21; for Briquet, 23. All scores are raw scores *P<.05. **p<.01. L, lie scale; F, (In) frequency; K, Korrection; NS, not significant.

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TABLE 2. Total AT6 DW b SB6 Lachar-Wrobel Problem Scales" DB b DTE6 SAb AA" FC6 PA6 SDC6 SS6

PAD (N = 2 3 . 0 12.0 2.8 2 . 0 4.7 3.3 1.8+ 1.2 0 . 9 + 1.4 1.9+ 1.7 0.9 1.1 1.6 1.5 1.0 1.0 0.7 0.7 1.4 1.3 5.3 3.7 29) Briquet's 40.5 14.6 5.2 2 . 8 7.4 3.4 2 8 + 1.6 2.2 1.8 3.1 + 2.0 1.2 1 2 1.8 1.5 1.7 1.1 1.6 1.2 2.2 1.6 11.2 4 . 3 syndrome (N = 37) T 5.21** 4.10" 3.21** 2.87** 3.32** 2.60* 0.91 NS" 0.58 NS" 2.68** 4.00** 2.27* 5.82** " All scores are raw scores. 6 AT, anxiety and tension; DW, depression and \NQn\/; SD, sleep disturbance; DB, deviant beliefs; DTE, deviant thinking and experience; SA, substance abuse; AA, antisocial activities; FC, family conflict; PA, problematic anger; SDC, sexual concerns deviation; SS, somatic symptoms; NS, not significant.

*p<.05.
**p<.01. TABLE 3. HS6 PAD (N = 29) Briquet's syndrome (N=37) T
a

MMPI Standard Clinical Scales" HY PD 59 5 + 11.9 71.2 + 12.2 3.92** PA PT SC 55.6+ 11.4 67.7+ 13.6 3.86** MA 49.5 10.4 58.3 12.7 3.02**

D 4 66 0 + 11 7 2. 72**

532 + 9.9 67.8+12.5 5.15**

54.1 + 13.0 67.4+ 12.7 4.16**

56.3 + 11 4 54.3 + 10.3 65.0 + 1 3 9 62.1 +11.4 2.71 2.83**

All scores are T scores. b HS, hypochondriasis; D, depression; Hy, hysteria; PD, psychopathic deviant; PA, paranoia; PT, psychasthenia; SC, schizophrenia; MA, mania.

**p<.01. TABLE 4. Interpersonal Alienation and Sensitivity"

SC1A" PD4A PA1 SC2C PD1 55.2 1 1 . 5 65912.4 FAM 56.5 1 1 . 1 PD2 52.010.2 AUT HOS IV P4 53.810.9 50.5 9.1 PAD 50.8 1 1 . 8 5 4 . 5 9 . 5 51.8 9.9 50.8 9.0 (N = 29) Briquet's 60.1 14.3 62.1 9 . 6 6 1 . 5 12.7 6 1 . 0 + 1 5 . 1 syndrome (N = 37) 3.21** 3.39" 3.23" T 2.80" 51.0 11.3 48.3 8.5 51.0 11.3 54.2 8.0 52.0 9.0 54.7 1 1 . 4

66.3 10 1 57.4 1 3 . 1

3.59"

3.76"

1.83 NS

1 71 NS

1.32 NS

1.33 NS

1.34 NS

' All scores are T scores. 6 SC1A, social alienation; PD4A, social alienation; PA1, overt paranoid, SC2C, loss ego mastery-behavioral; PD1, family conflict; FAM, family problems; PD2, problems with authority figures; AUT, Wiggin's problems with authority; HOS, Wiggin's hostility; IV, factor 4; P4, purified scale 4; NS, not significant.

* p < .05. "p<.01.

0.31 1.00 for PAD, t = 3.05, p < .01). The patients with Briquet's syndrome had significantly higher mean scores than did women with PAD on all eight standard clinical scales on the MMPI (Table 3). When test-taking attitude was controlled by statistical removal of the effect of the F/K statistic, the mean scores of the women with Briquet's syndrome remained sigmncantly higher on the hypochondnasis, hysteria, psychopathic deviant, and schizo, . , pnrema scales. v

intimacy (PAl); problems with controlling one's own behavior (SC2C); family discord and conflict (PDl and FAM); problems with authority and authority figures (PD2 and AUT); control of overt expression o f hostility (HOS); acting out (IV); or character patho l o g i c a l c o n d i t i o n s (P4) . T a b l e 4 s h o w s t h e m e a n s
a n d s t a n d a r d d e v i a t i o n s of t h e s e s c a l e s (T s c o r e s ) Women ^ Br syndrome had significantiy . , ? ,.. , . , ., , more interpersonal difficulties and problems than ... i ,,.,- ,-^, did women with PAD (F(l,64) = 15.78, p = .0002). Women with PAD were within three quarters of a standard deviation of the population mean on all s c a l e s . p a t i e n ts with Briquet's syndrome, on the other hand, were much higher on 6 of the 11 scales. They had more difficulty with social alienation (PD4A and SClA), family discord (FAM and PDl),

Interpersonal Alienation and Problems The scales that reflect problems with people inelude alienation and dislike of other people (SClA and PD4A); paranoia, distrust, and problems with
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suspicion and distrust (PAl), and self-control of their own behavior (SC2C). They were close to the population mean on authority problems (PD2 and AUT) and open hostility (HOS). These differences led to highly significant effects due to scale (F(10,640) = 8.80, p = .0001) and to a significant interaction between diagnosis and scale (F(10,640) = 3.23, p = .0004).

Somatoform Symptoms The MMPI has many widely used scales that reflect somatization. These include seven scales or subscales: HS, the hypochondriasis scale; D3, physical malfunctioning; HY3, lassitude-malaise; HY4, somatic complaints; SC3, bizarre sensory complaints; Org, Wiggins's somatic complaints; and Hea, Wiggin's denial of good health. The means for these scales are reported in Table 5. The results of an analysis of these scales was consistent with what we might expect. Women with Briquet's syndrome had significantly higher scores on all seven scales that reflect somatization (F(l,64) = 28.69, p < .0001). There was a significant scale effect (F(6,384) = 7.14, p < .0001) and a nonsignificant scale-by-diagnosis interaction (F(6,384) = 1.88, p > .05). The difference between the diagnostic groups was robust and could not be removed by controlling for the response set (F/K).

depressed women. These results parallel the findings of Guze et al. (12) on the variability in symptom reporting by patients with Briquet's syndrome nicely. On the validity scales that reflect emphasis on or exaggeration of psychopathological conditions, patients with Briquet's syndrome reported more complaints of all types and in all areas than depressed women. The increased number of complaints was not limited to somatic ones. It was not simply an effect of response set or current degree of distress, as measured by the F/K ratio because factoring out that ratio did not remove the significant relationship between diagnosis and the number of complaints. The second hypothesis that women with Briquet's syndrome would have more psychoform complaints than women with PAD was confirmed. They reported significantly more Lachar-Wrobel critical items in general and had more complaints in 9 of the 11 complaint groups. They also had significantly higher scores on each of the eight standard clinical scales than the other group. The number of scales over a T score of 70 and a over T score of 80 was significantly higher in the Briquet's group. Women with Briquet's syndrome do have more psychoform complaints. The third hypothesis predicted that women with Briquet's syndrome would have higher and more pathological scores on those scales sensitive to interpersonal alienation and problems than women with PAD. This hypothesis was confirmed. The Briquet's group scored higher on scales that reflect distance, discord, and problems with intimacy (PD4A, SClA, PAl, FAM, and PDl) and poor behavioral control (SC2C). They did not differ on scales that reflect overt aggression (AUT, PD2, and HOS). These results suggest a passive-aggressive style rather than an open antisocial one. The fourth hypothesis indicated that women with Briquet's disorder would report significantly more somatoform symptoms than would women with PAD. The results were strong and clear. The Briquet's group did differ from the depressive women

DISCUSSION

Our first hypothesis stated that women with Briquet's syndrome would differ significantly from women with PAD on the validity scales that assessed carelessness and exaggeration of distress. On the whole, our hypotheses were strongly validated. On those scales that indicated carelessness as a historian (TR and CLS), patients with Briquet's syndrome were less consistent in their responses to items than

TABLE 5. Mean Scores on Standard MMPI Somatization Scales" HS" PAD (N = 29) Briquet's syndrome (N = 37) T 53.2 9.9 67.8 12.5 5.15* D3 50.7 9.6 58.6 9.9 3.26* HY3 54.3 10.6 67.5 12.4 4.55* HY4 50.2 9.0 63.2 11.3 5.08" SC3 52.1 10.2 65.3 13.2 4.43* Org 51.3 10.3 65.6 13.6 4.72* Hea 52.7 9.9 65.6 12.9 4.46*

" All scores are T scores. b Hs, hypochondriasis; D3, physical malfunctioning; Hy3, lassitude/malaise; Hy4, somatic complaints; SC3, bizarre sensations; Org, somatic complaints; Hea, denial of good health.

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on many of the scales used. Women with PAD scored significantly lower on the following MMPI scales: HS, D3, HY3, HY4, SC3, Org, and Hea. The clinically important findings of this study include the observation that patients with Briquet's syndrome are not just patients with multiple somatoform complaints. They are also patients with multiple intrapsychic and interpersonal (psychoform) complaints. Part of this may be a response set (i.e., emphasizing problems and minimizing psychosocial assets) and part may reflect the chronicity of psychological illness. However, even when response bias is statistically equalized (F/K ratio factored out), patients with Briquet's syndrome still complain more than do women with PAD about both somatic and psychological problems. These patients present with multiple symptoms and syndromes in both general medicine (somatoform) and psychiatry (psychoform).

8.

9.

10. 11. 12. 13. 14. 15.

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book, Vol. 1. Minneapolis, MN, University of Minnesota Press, 1972 Harris RE, Lingoes, JC: Subscales for the MMPI: An aid to interpretation. In Dahlstrom WG, Welsh GS, Dahlstrom LE (eds), An MMPI Handbook, Vol. 1. Minneapolis, MN, University of Minnesota Press, 1972 Wood D, Othmer S, Reich T, et al: Primary and secondary affective disorder: I. Past social history and current episode in 92 depressed inpatients. Compr Psychiatry 18:201-210, 1977 Brim J, Wetzel RD, Reich T, et al: Primary and secondary affective disorder: Part II. Differences in usual state selfperceptions. Compr Psychiatry 21:388-395,1980 Brim J, Wetzel RD, Reich T, et al: Primary and secondary affective disorder: Part III. Longitudinal differences in depression symptoms. J Clin Psychiatry 45:64-69,1984 Guze SB, Cloninger CR, Martin RL, Clayton PJ: A followup and family diagnosis of Briquet's syndrome. Br J Psychiatry 149:17-23,1986 Guze SB, Cloninger CR, Martin RL, Clayton PJ: A followup and family study of schizophrenia. Arch Gen Psychiatry 40:1273-1276, 1983 Martin RL, Cloninger CR, Guze SB, Clayton PJ: Mortality in a followup of 500 psychiatric outpatients, I. Total mortality. Arch Gen Psychiatry 42:47-54, 1985 Cloninger CR, Martin RL, Clayton PJ, Guze SB: A blind followup and family study of anxiety neurosis: Preliminary analysis of the St. Louis 500. In Klein DF, Rabkin J (eds), Anxiety: New Research and Changing Concepts. New York, Raven Press, 1981 Feighner JP, Robins E, Guze SB, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972 SAS Institute Inc: SAS/STAT Guide for Personal Computers, Version 6. Cary, NC, SAS Institute, 1987 Greene RL: Assessment of malingering and defensiveness by objective personality inventories. In Rogers R (ed), Clinical Assessment of Malingering and Deception. New York, Guilford Press, 1988, 123-158 Buechley R, Ball H: A new test of "test validity" for the group MMPI. J Consult Clin Psychol 16:299-301, 1952 Greene RL: An empirically derived MMPI carelessness scale. J Clin Psychol 34:407-410, 1978 Lachar D, Wrobel TA: Validating clinicians' hunches: Construction of a new MMPI critical item set. J Consult Clin Psychol 47:277-284, 1979

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