Nwokocha et al.

Int J Ment Health Syst (2017) 11:57

DOI 10.1186/s13033-017-0161-3 International Journal of
Mental Health Systems

RESEARCH Open Access

Somatization disorder
among adolescents in southeast Nigeria: a
neglected issue
A. R. C. Nwokocha1, J. M. Chinawa1,5*, V. Onukwuli1, A. Ubesie1, Appolos Ndukuba2, A. T. Chinawa3,
Elias Aniwada4 and Samuel Uwaezuoke1

Abstract 
Background:  Adolescents do present with somatization disorder which is often neglected by pediatricians. This
could have serious consequences if not curbed early.
Objectives:  This study is aimed at determining the pattern and types of Somatization disorder among adolescents
attending secondary schools in south east Nigeria.
Methods:  Somatization disorder was investigated among 485 adolescents from mixed schools using a stratified
random sampling of adolescents from four secondary schools in southeast Nigeria. The Enugu somatization scale was
used to evaluate for presence of somatization in the participants. Statistical analysis was with statistical package for
social sciences (SPPS) version 19 (Chicago IL).
Results:  A total of 485 adolescents aged 10–19 years were included in this study. The mean age of the respond-
ents was 16.36 with standard deviation (SD) of 3.14 years. Two hundred and fifty-one (51.8%) had head features, 262
(54.0%) had body features, 303 (62.5%) had either head or body features while 210 (43.3%) had both head and body
features. One hundred and thirty-four males (51.3%) compared to 117 females (52.2%) reported symptoms consistent
with head symptoms (p = 0.038). One hundred and eleven males (42.5%) compared to 99 females (44.2) reported
symptoms related to the head and body (p = 0.137) while 135 males (51.7%) compared to 127 females (56.7%)
reported symptoms related to the body (p = 0.925). There were significant associations of age in categories with
head, body, either head or body as well as both head and body features (all p value <0.001).
Conclusions:  Psychosomatic problems do exist and may be on the rise among adolescents.
Keywords:  Psychosomatic disorder, Adolescents, Secondary schools, Nigeria

Background defined as multiple, recurrent and frequently changing

Somatization disorder (SD) as a psychiatric diagnosis physical symptoms usually present for several years; (at
became entrenched in the DSM-IV (2000) to reflect the least 2 years) before the patient is referred to a psychia-
condition hitherto known as Briquet’s syndrome which is trist [2]. There are significant departures from the DSM-
a polysymptomatic condition that starts before the age of IV categorization which identified somatization disorder,
30 years and extends for a long time [1]. It is character- hypochondriasis, pain disorder, and undifferentiated
ized by pains, gastrointestinal, genitourinary and pseudo- somatoform disorder. All these are now included under
neurological symptoms. In the ICD-10, somatization is the heading of SD [2]. In addition, the symptoms need
no longer to be medically unexplained but may or may
not be associated with another medical condition. This
*Correspondence: josephat.chinawa@unn.edu.ng
5
implies that adolescents who had organic co- morbidities
Department of Pediatrics, UNTH, PMB 01129, Enugu 400001, Enugu
State, Nigeria
who were previously excluded under DSM-IV can now
Full list of author information is available at the end of the article

© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Nwokocha et al. Int J Ment Health Syst (2017) 11:57 Page 2 of 7

be included in the diagnosis of SD and be considered for contribute to the difficulties faced by them in managing
appropriate treatment. an adolescent presenting with this condition. Interest-
It has been generally believed that this disorder occurs ingly, Smith [17] had shown that the health care costs
predominantly in non-western and developing socie- declined by 53% when primary care physicians treated
ties. However, there is growing evidence that suggests their somatizing patients appropriately.
that somatic disorder is a hidden malaise that presents in Considering that adolescents make up a significant
large numbers all over the world, but is often under diag- proportion of the Nigerian population and that a recent
nosed [3]. This behavioral problem among adolescents is study of adults with mental health disabilities docu-
common in all cultural groups and societies, especially in mented that their problems reportedly started in early
the primary care [4]. With the burden of this problem in adolescence or around 14 years of age and given the seri-
view, it is believed that it will give the pediatric adoles- ous negative impact of mental health problems, there is
cent specialist some hint that his patient, who may deny need to evaluate children and adolescents for somatiza-
any psychic distress, is actually under some unbearable tion disorder, a very common mental health problem
psychological states [5]. It is seen that when the adoles- [18]. This is particularly so in south-east Nigeria where
cents is diagnosed with somatic problems, it makes the studies are scanty that have focused on childhood and
adolescent withdrawn from his peers and is often been adolescent somatic disorders.
stigmatized as been abnormal and psychotic. Thus the This study is aimed at determining the types somati-
Nigerian adolescent cannot afford to even discuss this zation disorder among adolescents attending secondary
problem with his parents or teachers since he/she may be schools in South east Nigeria. It is hoped that this study
forced to cope with somatic distress for a long time [5–9]. will add to the knowledge of this disorder and will alert
Reported prevalence of somatization varies depending the pediatrician of its existence among children and ado-
on the criteria. It has been noted that about 50% of ado- lescent age group.
lescents who attend pediatric clinic will complain of medi-
cally unexplained symptoms with significant functional Methods
and emotional impairment. Such adolescents pose heavy Setting
burdens on the healthcare system through frequent utili- The study was carried out among adolescents in four second-
zation of health resources and hospitalizations, specialist ary schools in Enugu and Ebonyi States of south east Nigeria.
consultations, unnecessary investigations, and treatments
[10, 11]. In addition to the negative impact of the associated Study design
co-morbidities, family conflict and school absenteeism, fail- A descriptive cross sectional study was used to identify
ure to make accurate and timely diagnosis often results in the pattern and types of PSDs among adolescents attend-
multiple referrals, repeated unnecessary diagnostic tests, ing secondary schools in South east Nigeria.
unjustified and potentially harmful treatments including
medication trials and even surgeries, and the perpetuation Sampling
of the belief of underlying organic illness [12]. Four secondary schools were selected in Enugu and
Accurate diagnosis and treatment of adolescent somatic Ebonyi metropolis through stratified random sampling
problem can make a great difference in patients’ life and method. The schools were stratified using state and
in pediatrician or physician satisfaction. These treatment nature of school that is whether unisex or mixed schools.
approaches involve a multidisciplinary approach which Two same gender schools and two co-educational schools
aims at targeting the adolescent/family’s understanding were utilized. The schools selected were proportionately
of the mind–body relationship and their acceptance of allocated number of participants. From a total 3654 ado-
the bio-psycho-social formulation and treatment [13]. lescent students in all chosen schools, 485 adolescents
However, Ohaeri and Olatawura have observed the resil- were selected using random sampling.
ience of SD to physical methods of treatment [14].
Managing somatization disorder often poses challenges Data collection
to the physician. The reasons would include ignorance of A pretested self-administered Enugu somatization scale
the condition [15]. As Ndukuba et  al. [16] noted, there (ESS) developed by Ebigbo [6] was used for this study.
is a poor knowledge of conversion disorders by pedia- The Enugu somatization scale is a culture specific screen-
tricians in Nigeria and this could delay identification of ing scale that measures the culture-bound illness soma-
children and adolescents with somatoform disorders. In tization. This instrument was developed bearing in mind
addition, the drive to rule out organic disease, the fear the shortcomings or uncertainties that accompanies the
of missing organic diseases and the poverty of skills in use of western methods of assessment techniques and
exploring psychological issues by most physicians could also to figure out the nature of psychological problem
Nwokocha et al. Int J Ment Health Syst (2017) 11:57 Page 3 of 7

behind somatic symptoms as presented by Enugu, Nige- also obtained from the principals of the selected schools,
rian patients. The ESS is a 65-item scale. The scale was who acted as the legal guardians of the students.
found to distinguish patients from normals [6]. It has two This article is aimed at determining the types and fac-
sub-scales. The first is the HEAD subscale, captured by tors associated with PSDs among adolescents attending
items 1–23, while the BODY subscale is captured by items secondary schools in South east Nigeria. Subjects who
24–65. The ESS has a dichotomous response options gave consent were included in this study while those
which are YES and NO. It has been cross-validated with without consent and those with obvious psychiatric dis-
neurotic illness questionnaire (NIQ) in India where the orders were excluded.
ESS was found to correlate significantly with NIQ [7]. The
ESS is a dichotomous response scale with YES and NO Results
representing the dichotomies. A score of 1 is assigned to Demography
any Yes while a score of 0 is assigned to any NO response. A total of 485 adolescents aged 10–19  years were
With the exception of item 55 which is positively worded, included in this study. Their median age was 16 (1QR:
all other items on the ESS are scored by the number of 15–17) years. Two hundred and sixty-one (53.8%) were
positive responses. Interpretation of score was based on males. Table 2 shows the socio-demographic characteris-
the norm produced by the author. See Table 1. tics of respondents. The mean age of the respondents was
The questionnaires were completed by the students 16.36 with standard deviation (SD) of 3.14 years. Major-
under strict examination conditions during class hours ity were aged 15–19 years.
after explanation of the purpose of the study. Confiden-
tiality was assured by informing the respondents not to Prevalence of psychosocial disorder
write their names on the questionnaires. The class teach- Table 3 shows the distribution and pattern of Somatiza-
ers were excluded from the class during the exercise to tion disorder. Two hundred and fifty-one (51.8%) had
avoid their possible influence.
Table 2  Socio-demographic characteristics of respondents
Data analysis
Statistical analysis was with statistical package for social Socio-demographic characteristics Total (N) = 485
sciences (SPPS) version 19 (Chicago IL). Chi square test Frequency (n) Percent (%)
was used to test for statistical association of age in cat-
Age in categories (years)
egories as well as sex with presence or absence of psy-
 10–14 64 13.2
chosocial disorder. Binary logistic regression was used
 15–19 421 86.8
to control for confounding. All reported p values are
Mean (SD) 16.36 (3.14)
2-sided and values <0.05 were assumed as significant.
Sex
 Female 224 46.2
Ethical consideration
 Male 261 53.8
Ethical approval for the study was obtained from the
Health Research Ethics Committee of the University of
Nigeria Teaching Hospital, Ituku-Ozalla, Enugu. Permis-
sion and approval were obtained from post primary edu- Table 3  Distribution and pattern of somatization disorder
cation board of each state as well as from principals of Somatization disorder Total (N) = 485
each school studied. Assent was obtained from the stu- Frequency (n) Percent (%)
dents after a detailed explanation of the study objectives,
procedures, risks and benefits. Informed consent was Head
 Absence 234 48.2
 Presence 251 51.8
Table 1  Norms for the Enugu summarization scale Body
Students  Absence 223 46.0
 Presence 262 54.0
Male Female
Either head or body
Head  Absence 182 37.5
 Mean scores 3.58 4.12  Presence 303 62.5
Body Both head and body
 Mean scores 7.22 7.73  Absence 275 56.7
 Std. dev. 4.40 2.81  Presence 210 43.3
Nwokocha et al. Int J Ment Health Syst (2017) 11:57 Page 4 of 7

head features, 262 (54.0%) had body features, 303 (62.5%) disorder (U  =  .18555.0, p  <  0.001). The median age of
had either head or body features while 210 (43.3%) had adolescents that reported head symptoms was 16 (range:
both head and body features. 10–19) years compared to 15 (range: 10–19) among those
without head symptoms (U = .21873.0, p = 0.002). Simi-
Gender and somatization disorder larly, the median age among adolescents that reported
One hundred and thirty-four males (51.3%) compared to body symptoms was 16 (range: 13–19) years compared to
117 females (52.2%) reported symptoms consistent with 15 (range: 10–19) among those without body symptoms
head symptoms (p  =  0.038). One hundred and eleven (U = .21014.0, p < 0.001). The proportion of adolescents
males (42.5%) compared to 99 females (44.2) reported that reported somatization symptoms across the various
symptoms related to the head and body (p = 0.137) while ages is shown in Table 4.
135 males (51.7%) compared to 127 females (56.7%) Table  4 shows the relationship between socio-demo-
reported symptoms related to the body (p  =  0.925) as graphic characteristics and somatization disorder. There
depicted in Table 4. were significant associations of age in categories with
head, body, either head or body as well as both head
Age and somatization disorder and body features (all p value <0.001). The respondents
The median age among adolescents that had somati- that were aged 15–19  years were; about 4 times (AOR
zation disorder was 16 (13–19) years compared to 15 4.2; 95% CI 2.7–7.7) likely to have head features, about
(range: 10–19) years among those without somatization 5 times (AOR 4.7; 95% CI 2.5–8.6) likely to have body

Table 4  Relationship between socio-demographic characteristics and somatization disorder

Socio-demographics Total (N) = 485 Bivariate analysis Multivariate analysis
χ2 (p value) AOR (95% CI)
Absence Presence
Freq (%) Freq (%)

Head
 Age categories (years)
  10–14 49 (76.6) 15 (23.4) 23.674 (0.000) 1
  15–19 185 (43.9) 236 (56.1) 4.2 (2.7–7.7)
 Sex
  Female 107(47.8) 117(52.2) 0.038(0.845) NA
  Male 127(48.7) 134(51.3)
Body
 Age categories (years)
  10–14 49 (76.6) 15 (23.4) 27.764 (0.000) 1
  15–19 174 (41.3) 247 (58.7) 4.7 (2.5–8.6)
 Sex
  Female 97 (43.3) 127 (56.7) 1.200 (0.273) NA
  Male 126 (48.3) 135 (51.7)
Head or body
 Age categories (years)
  10–14 45 (70.3) 19 (29.7) 33.807 (0.000) 1
  15–19 137 (32.5) 284 (67.5) 4.9 (2.8–8.8)
 Sex
  Female 79 (35.3) 145 (64.7) 0.905 (0.341) NA
  Male 103 (39.5) 158 (60.5)
Head and body
 Age categories (years)
  10–14 53 (82.8) 11 (17.2) 20.475 (0.000) 1
  15–19 222 (52.7) 199 (47.3) 4.3 (2.2–8.5)
 Sex
  Female 125 (55.8) 99 (44.2) 0.137 (0.712) NA
  Male 150 (57.5) 111 (42.5)
Nwokocha et al. Int J Ment Health Syst (2017) 11:57 Page 5 of 7

features, about 5 times (AOR 4.9; 95% CI 2.8–8.8) likely instrument well and thus respond appropriately. On the
to have either head or body features and about 4 times other hand, it is likely that social desirability bias on the
(AOR 4.3; 95% CI 2.2–8.5) likely to have both head and part of the respondents could have contributed to the
body features than those aged 10–14 years. high rates of endorsement seen in this study.
That nearly same proportion of participants that
Discussion had symptoms referred to the head also had symptoms
The symptoms of psychosomatic disorders usually begin referred to the body could reflect the poly-symptomatic
during adolescence or early adulthood and are character- nature of the condition.
ized by many vague physical complaints. Any part of the This study did not find any gender difference in the
body may be affected, although the symptoms and their endorsement of symptoms except that males presented
frequencies vary. Common symptoms of this disorder with head symptoms more than females. This is in agree-
among adolescents are headaches, nausea and vomit- ment with other studies that have reported the oblitera-
ing, abdominal pain, diarrhea or constipation, fatigue, tion of gender differences in most psychiatric disorders
fainting, dizziness, sleeping problems, and nervousness. during adolescence [26].
The most frequently seen symptoms among adolescents This study finds that participants with symptoms were
should be differentiated from psychosomatic disorders older than those without symptoms. The reason for this
seen among adults [19]. is not clear but considering that the condition is charac-
Fifty-one point eight percent (51.8%) of these adoles- terized by its chronic nature, it is likely that the number
cents with this disorder reported symptoms related to the of adolescents with the condition would increase with
head while 54% reported symptoms involving the body increasing age.
and 62.5% had either head or body features while 43.3% The above discussion goes to portend the fact that a
had both head and body features. This high prevalence gamut of policy initiatives is needed to adequately provide
is similar to that obtained by Ibeziako et  al. [11] who for effective early mental health services for adolescents
reported a prevalence of 50% but at variance with that of and their families. This policy must range from enhanced
Gureje et al. [4] who found Nigerians to have less preva- awareness of mental health issues and points of service
lence of somatization compared to Latin Americans. The access, development of effective techniques for identifica-
prevalence obtained in this study is also higher than that tion and intervention, destigmatization of mental health
of Arnold et  al. [20] who reported a low prevalence of problems, preparing pediatric psychologists for Collabora-
17% in his study. Abdulbari et al. [21] also noted a preva- tive roles in early childhood mental health services, fund-
lence rate of 23.9% among Qatari adults. Cultural and ing for early childhood mental health service needs, family
geographic construct as well as sample size, methodol- involvement in determination of service needs and poli-
ogy and differences due to developmental age could also cies and research aimed at broadening the range of effec-
account for this variations in prevalence. tive diagnostic and intervention [27–29]. Apart from these
During the last decade, studies in several countries policies, we also recommend rotations in child psychiatry
have shown that the proportion of adolescents with psy- for pediatric residents as an optional elective posting.
chosomatic complaints (PSC) increased [5–9]. In Japan This study is limited by the fact that self-rated ques-
there is a considerable rise in the number of children pre- tionnaire was used. The response could be subject to
senting with psychosomatic disorders [22, 23]. The main social desirability bias. Moreover, the instrument being
symptoms in these children include headache, abdominal dichotomous makes it difficult to rate the severity of the
pain, and poor early rising. Children having two or more symptoms. However, the strength of the study is in using
symptoms were reported to range about 20–30%. Pupils a locally developed instrument that is culturally accept-
who come to school infirmaries with physical symptoms able. This study contributed in highlighting a possible rise
related to psychosomatic disorders have increased to in prevalence of somatization disorder in this culture and
more than 15% per week [24, 25]. the need to carry out more detailed study on this issue in
It is not clear therefore whether the high prevalence the nearest future (Additional file 1).
found in this study reflects rising incidence of psycho-
pathologies among the adolescent population. Could it Conclusion
be that these social and cultural changes are beginning to Psychosomatic problems do exist and may be on the rise
take a toll on the mental health of the adolescents? among adolescents.
The strength of this study is that it utilized an instru-
ment developed locally, which considered the cul- Additional file
tural issues specific to the region. One would therefore
expect the respondents to understand the items of the Additional file 1. Strobe statement checklist.
Nwokocha et al. Int J Ment Health Syst (2017) 11:57 Page 6 of 7

Abbreviations 2. American Psychiatric Association. Diagnostic and statistical manual of

SD: somatization disorder; ESS: Enugu somatization scale; SPSS: statistical mental disorders. 5th ed. Washington, DC: American Psychiatric Associa-
package for social sciences program. tion; 2013.
3. Isaac M. Somatization–a culture-bound or universal syndrome? J Mental
Authors’ contributions Health. 1996;5:219–22.
JMC, ARN, NAC, AU, VO and sATC contributed to the conception, writing and 4. Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural
proof reading of this manuscript. JMC contributed to writing of the manu- perspective: a World Health Organization study in primary care. Am J
script. All authors proofread the article. All authors read and approved the final Psychiatry. 1997;154:989–95.
manuscript. 5. Ebigbo PO. A cross sectional study of Nigerian females using the Enugu
Somatization Scale. Cult Med Psychiatry. 1986;10:167–85.
Author details 6. Graber JA, Lewinsohn PM, Seeley JR, Brooks-Gunn J. Is psychopathology
1
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2
 Department of Psychological Medicine, University of Nigeria, University 7. Ebigbo PO, Janakiramiah N, Kumaraswamy N. Somatization in cross
of Nigeria/Teaching Hospital (UNTH), Ituku‑Ozalla, Enugu State, Nigeria. cultural perspective. In: Peltzer K, Ebigbo PO, editors. Clinical Psychology
3
 Department of Community Medicine, ESUT Teaching Hospital, Enugu, in Africa. Enugu: Chuka printing Company Ltd; 1989. p. 233–50.
Enugu State, Nigeria. 4 Department Community Medicine, College of Medi- 8. Nichter M. Idioms of distress: alternatives in the expression of psy-
cine, University of Nigeria, University of Nigeria/Teaching Hospital (UNTH), chosocial distress: a case study from south India. Cult Med Psychiatr.
Ituku‑Ozalla, Enugu State, Nigeria. 5 Department of Pediatrics, UNTH, PMB 1982;5:379–408.
01129, Enugu 400001, Enugu State, Nigeria. 9. Ebigbo PO. The development of a culture-specific (Nigeria) screening
scale of somatic complaints indicating psychiatric disturbance. Cult Med
Acknowledgements Psychiatry. 1982;6:29–43.
We acknowledge Miss Carol that helped in data entering. We also acknowl- 10. Kirmayer LJ, Young A. Culture and somatization: clinical, epidemiological,
edge the adolescents who gave us consent to carry out this work. and ethnographic perspectives. Psychosom Med. 1998;60:420–30.
11. Ibeziako P, Bujoreanu S. Approach to psychosomatic illness in adoles-
Competing interests cents. Curr Opin Pediatr. 2011;23:384–9.
The authors declare that they have no competing interests. 12. Gupta A, Lang AE. Psychogenic movement disorders. Curr Opin Neurol.
2009;22:430–6.
Availability of data and materials 13. Lopes de Mello L. 2010. Psychosomatic disorders. In: Stone JH, Blouin M,
All the data supporting our findings is contained within the manuscript. editors. International encyclopedia of rehabilitation. http://cirrie.buffalo.
Moreover, information on supplementary data is available on http://www. edu/encyclopedia/en/article/139/. Accessed 24 Aug 2015.
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Consent to participate 15. Quill T. Somatization disorder: one of medicines’ blind spots. JAMA.
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Knowledge of conversion disorder in children by pediatricians in a devel-
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19. Brill SR, Patel DR, MacDonald E. Psychosomatic disorders in pediatrics.
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Publisher’s Note children: an emerging challenge to health care in Japan. Pediatr Int.
Springer Nature remains neutral with regard to jurisdictional claims in pub- 2002;44:153–6.
lished maps and institutional affiliations. 24. Aro H. Life stress and psychosomatic symptoms among 14 to 16-year old
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