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Medically
Unexplained Illness
Gender and Biopsychosocial Implications

SUSAN K. JOHNSON

American Psychological Association

Washington, DC
Copyright © 2008 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publication
may be reproduced or distributed in any form or by any means, including, but not limited
to, the process of scanning and digitization, or stored in a database or retrieval system,
without the prior written permission of the publisher.
Published by
American Psychological Association
750 First Street, NE
Washington, DC 20002
www.apa.org
To order
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P.O. Box 92984
Washington, DC 20090-2984
Tel: (800) 374-2721; Direct: (202) 336-5510
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Typeset in Goudy by Stephen McDougal, Mechanicsville, MD
Printer: Maple-Vail Book Manufacturing, Binghamton, NY
Cover Designer: Scribe Typography, Port Townsend, WA
Technical/Production Editor: Harriet Kaplan
The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.
Library of Congress Cataloging-in-Publication Data
Johnson, Susan K.
Medically unexplained illness: gender and biopsychosocial implications / by Susan K.
Johnson. — 1st ed.
p. cm.
Includes bibliographical references.
ISBN-13: 978-0-9792125-8-1
ISBN-10: 0-9792125-8-8
1. Somatoform disorders. 2. Chronic fatigue syndrome—Etiology. 3. Multiple chemical
sensitivity—Etiology. 4. Fibromyalgia—Etiology. 5. Sex differences (Psychology)
I. American Psychological Association. II. Title.
[DNLM: 1. Psychophysiologic Disorders—psychology. 2. Psychophysiologic Disorders—
therapy. 3. Fatigue Syndrome, Chronic. 4- Fibromyalgia. 5. Irritable Bowel Syndrome.
6. Sex Factors. WM 90 J69m 2007]
RBI 13.J6448 2007
616'.0478—dc22 2007010292
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
For Dennis, Elise, and Caroline
 CONTENTS

Foreword ix
Introduction 3

I. Overview of Medically Unexplained Illness 9

Chapter 1. A Brief History of Gender in Medically
Unexplained Illness 13
Chapter 2. Psychiatric Disorder in Medically Unexplained
Illness 21
Chapter 3. Psychosocial and Cognitive Factors in
Medically Unexplained Illness 31
Chapter 4. Biology of Medically Unexplained Illness . . . . 49

II. Common Medically Unexplained Illnesses 61

Chapter 5. Irritable Bowel Syndrome 67
Chapter 6. Fibromyalgia 89
Chapter 7. Chronic Fatigue Syndrome 115
Chapter 8. Multiple Chemical Sensitivity 131

III. General Treatment Issues in Medically Unexplained

Illness 145
Chapter 9. Treatment Approaches to Irritable Bowel
Syndrome 149
 Chapter 10. Treatment Approaches to Fibromyalgia 163
Chapter 11. Treatment Approaches to Chronic Fatigue
Syndrome 173
Chapter 12. Treatment Approaches to Multiple Chemical
Sensitivity 181
Chapter 13. Conclusion: Understanding Medically
Unexplained Illness 185

References 189
Author Index 247
Subject Index 261
About the Author 271

viii CONTENTS
 FOREWORD

Medical practitioners are taught fact-based medicine. They are taught

to use a patient's story of his or her illness as a path to suggest various diag-
noses confirmed in part by the physical examination and then more defini-
tively by appropriate laboratory testing. Unfortunately, the fact-based ap-
proach often is not sufficient. This is because many patients seen in the
outpatient setting have complaints or symptoms with no detectable abnor-
mality. The most common of these are fatigue, pain, or achiness—either in
localized parts of the body such as the head or abdomen or throughout the
body, problems with sleep, or feeling as if it is hard to concentrate (a com-
plaint that patients will often call "brain fog")- The practitioner has no ba-
rometer with which to gauge fatigue and has to turn to the neuropsychologist
for help in gauging brain fog. With patients who complain of pain, the prac-
titioner can often find tenderness on palpation but no hint as to why it ex-
ists. So even if the examination can elicit abnormal signs such as tenderness
or abnormalities on cognitive testing, the results often do not point to a
definitive diagnosis, which leaves the practitioner without an explanation.
This can lead to a disconnect between what the patient is expecting to hap-
pen and what actually does happen in the doctor's office. When the medical
model fails, practitioners turn to psychogenic mechanisms. If they cannot
find a physiological cause for symptoms, they believe that none exists. This
leads to the conclusion that patients are either making up their pain or that
it is "all in their heads." Some doctors actually say as much; others prefer to
tell their patients that "nothing is wrong." Patients leave the doctor's office
feeling dissatisfied and still ill. They have fallen between the cracks of classi-
cal medicine and are on their own. This is probably the biggest reason that
vitamins and health-related foods are now a billion-dollar industry in America.
Of course, this scenario represents a failure of the medical profession to
care for the patient. If a diagnosis doesn't fit, reject the patient! However,
this is the antithesis of what a doctor should be doing, and that is whatever
helps the patient feel better. Somehow, the fact-based approach to medicine,
with its need to solve the medical puzzle, has trumped the original reason for
the existence of the medical profession. In the high-tech world of modern
medicine, the patient with disabling symptoms but no definite illness is left
on his or her own. George Engel's1 biopsychosocial approach to illness has
fallen to the wayside.
The consequences of this shift are just now hitting the American medi-
cal educational system with the following questions for the near future. Who
is going to take care of all these patients? How can we increase this number
by shifting the focus from the machine back to the patient? How can we
teach doctors to deal with uncertainty when they are trained to be comfort-
able only when they know all the answers?
Answering these questions constitutes a process in education. Susan K.
Johnson's book is a clear step in this process. The book is a rarity in that it
provides one scholar's synthesis, integration, and conclusions from many
complex and often contradictory studies. To the inquisitive, the book opens
many research questions. To the practitioner, the book provides an up-to-
date review of what is known and how to apply it to the patient, and it does
this in a way in which the clinician, whether a psychologist or a physician,
can learn the biological bases for these medical problems. Thus, the person
who reads this book can understand the pathophysiological bases for the prob-
lems seen in the office. This broad background is critical for the future re-
search that is needed to improve the therapeutic armamentarium available
to the practitioner. However, the biopsychosocial component reviewed in
depth herein is also a critical factor, because it makes the point that the
practitioner can develop a prescription hand tailored to each patient that
can lead to reduced symptoms and thus better health. A careful reading of
this book plus a bit of thought will make you a better caregiver. Patients will
leave your office feeling better rather than feeling lost or rejected, as is too
often the case with classical medicine today.

Benjamin Natelson, MD

'Engel, G. (1977, April 8). The need for a new medical model: A challenge for biomedicine. Science,
196, 129-136.

X FOREWORD
Medically Unexplained Illness
 INTRODUCTION

Interest in medically unexplained illnesses (MUIs) is on the rise, not

surprising considering that they constitute the most common disorders seen
in primary care (Kroenke et al, 1997). MUIs are syndromes characterized by
multiple symptoms, significant suffering, and disability that fail to show con-
sistent pathophysiology (Barsky & Borus, 1999). MUIs present a conundrum
for conventional biomedical approaches. Their high degree of prevalence,
together with chronicity, attendant disability, and skyrocketing costs to the
health care system, have fed this interest. Undoubtedly, some of the recent
fascination with MUIs is related to the clues they offer to the mind-body
relationship. Research in the physiology of these illnesses in an attempt to fit
them into the biomedical model has illuminated both the inadequacy of the
biomedical model and the bidirectional nature of the biobehavioral transac-
tion. This volume tackles the complex nature of the mind-brain-behavior
relationship.
The guiding purpose of this book is to present a balanced, biopsychosocial
approach to exploring the role of gender in several representative MUIs. An
inclusive classification of MUIs would include such illnesses as chronic fa-
tigue syndrome (CFS), fibromyalgia (FMS), premenstrual syndrome, chronic
pelvic pain, irritable bowel syndrome (IBS), multiple chemical sensitivities
(MCS), Gulf War syndrome, temporomandibular joint dysfunction (TMD),
noncardiac chest pain, hyperventilation syndrome, and tension headaches
(Manu, 2004; Wessely, Nimnuan, & Sharpe, 1999). Common factors among
all the MUIs are a lack of sufficient medical explanation, significant im-
pairment in functioning, and female predominance. Many labels have been
used in the literature to describe these conditions, such as medically unex-
plained symptoms, functional somatic syndromes, chronic dysfunctional illnesses,
functional stress syndromes, chronic multisymptom illnesses, affective spectrum
disorders, multisomatoform disorders, antidepressant responsive disorders, and
unexplained illnesses. Although the literature often notes that these syn-
dromes are poorly understood and underresearched, there is actually an
abundance of research in a wide variety of disciplines, ranging from physi-
ology, medicine, psychology, sociology, and epidemiology to public health,
but these disparate reports do not always acknowledge the contributions
from other areas. The research from these myriad fields can contribute to a
further biopsychosocial understanding of MUIs and their preponderance
in women.
Female predominance is well documented and established in MUIs,
but the reasons for this gender disparity are still unclear (Jason, Taylor, Song,
Kennedy, & Johnson, 1999; Toner, 1995; Wessely et al, 1999; Whitehead,
Palsson, & Jones, 2002; Wool & Barsky, 1994). Relatively few investigators
have broached this topic other than to note the prevalence of disparities
between genders. The ratio of women to men is generally reported to 2:1 for
irritable bowel syndrome (IBS; Mayer, Naliboff, Lee, Munakata, & Chang,
1999) and CFS (Evengard, Jacks, Pedersen, & Sullivan, 2005; Lindal,
Stefansson, & Bergmann, 2002), 9:1 for FMS (Gran, 2003; Yunus, 2001),
and 4:1 for MCS (Fiedler & Kipen, 1997). Since vital health statistics have
been recorded in the United States, mortality rates have been higher among
men, whereas morbidity from acute and chronic conditions, short-term dis-
ability, health care use, and medical drug use have been higher among women.
Men suffer more than women do from life-threatening diseases that cause
earlier death. Women live longer than men, but they also live "sicker," re-
stricting their activity and spending more days in bed. The differences are
largest during the reproductive years for women, yet even when reproductive
conditions are excluded, differences in morbidity remain (Verbrugge, 1985).
The reproductive age is also the prime age for the development of MUIs,
although these illnesses (with the exception of premenstrual syndrome) are
not closely related to women's reproductive physiology. Because they are so
prevalent and disabling, MUIs account for a great deal of women's morbidity
(Wessely et al., 1999).
This book is based on the premise that there is an interaction of physi-
ological, psychological, and sociocultural variables that contribute to female
predominance in MUIs. The relative influence of these three factors varies
among individuals. The trauma of childhood sexual abuse may be strongly
salient for one individual with FMS or IBS, whereas another may be psycho-

4 MEDICALLY UNEXPLAINED ILLNESS

logically unscathed yet have neuroendocrine dysfunction expressed as
hypocortisolism and resulting in fatigue, sleep difficulties, pain symptoms,
and reduced coping abilities.
Accordingly, the approach to understanding the relationship between
gender and MUIs must be interdisciplinary. This book presents a
biopsychosocial model for several representative MUI syndromes: IBS, FMS,
CFS, and MCS. These four syndromes are explored in depth because they
represent a broad spectrum of body systems. They range in terms of medical
legitimacy from IBS (less controversial and more accepted) to MCS (more
controversial and less clearly defined). These syndromes challenge traditional
perspectives on illness and demand innovative paradigms to advance our
understanding. By examining the empirical evidence through the lens of gen-
der, this book shows that MUIs result from an interaction of physiological,
psychological, interpersonal, and sociocultural factors that affect symptom
expression differently in men and women.
A brief history of MUIs is presented in chapter 1. Chapter 2 addresses
the issue of comorbidity of somatization, depression, and anxiety in MUIs as
well as the high co-occurrence of somatization with other psychiatric disor-
ders and the high rates of health care use by people with somatizing tenden-
cies. Bidirectional processes in MUIs (the psychosocial factors discussed in
chap. 3) influence physiological processes presented in chapter 4, and physi-
ological processes impact the psychosocial experience of the patient. Chap-
ter 3 highlights the explanations for gender differences in symptom report-
ing, sensation thresholds, stressful life events, and health care seeking.
Additionally, chapter 3 explores the problem faced by people with MUIs of
having to prove the legitimacy of their illnesses when the medical system
does not validate their illness experiences. Because patients recognize the
stigma of psychiatric diagnosis, much patient activism is directed toward
achieving a medical diagnosis. The evidence for hypothalamic—pituitary—
adrenocortical axis, autonomic, and neuromuscular dysregulation in patients
with medically unexplained syndromes, such as cortisol and serotonin defi-
ciencies, smooth muscle contractions, and central nervous system and vis-
ceral hypersensitivity, are presented in chapter 4- These biological alterations
may be experienced as symptoms by the patient. The influences on this pro-
cess are cognitions (beliefs, interpretations, attributions, expectancies), mood
factors (depression, anxiety), and sociocultural expectancies, which differ
for men and women. These psychosocial differences influence MUIs through
biological systems that mediate sensation and function and through the de-
velopment of illness behavior.
Part II considers the arguments for approaching MUI as one syndrome
or as distinct syndromes. Chapters 5 through 8 present a detailed analysis of
the state of current research on IBS, FMS, CFS, and MCS. Approaches to
epidemiology, classification criteria, biopsychosocial etiology, gender influ-
ences, course of illness, and outcomes for these MUIs are discussed.

INTRODUCTION 5
 General treatment issues in MUIs are addressed in Part III. The effi-
cacy of approaches such as pharmacology, cognitive-behavioral treatments,
stress management, hypnotherapy, and graded exercise are presented. Treat-
ment for women with MUIs should take into consideration the unique thera-
peutic needs of women in relation to socialization around issues of self-
esteem, assertiveness, role strain, and dependency. Sex-specific triggers such
as history of sexual abuse, battering, stressful life events, and the relation of
symptoms to menstrual cycle or hormonal events should all be addressed as
part of an individualized treatment approach. The experience of some pa-
tients who engage in endless rounds of "doctor shopping," in fruitless at-
tempts to legitimate their illness experiences, results in frustration in pa-
tients and physicians alike. Doctor shopping can also result in excessive
medical testing and overprescribing of pharmaceuticals, which can result in
iatrogenic symptoms. Physicians often view unexplained symptoms as a threat
to medical competence and dismiss such symptoms as psychogenic. This does
not satisfy the patient whose physical body is suffering and who views psy-
chological explanations as inadequate and stigmatizing.
A helpful approach discussed in Part III is the framing of MUIs as stress
disorders, thereby providing an entry intro framing the biopsychosocial ap-
proach for the patient and emphasizing the importance of stress manage-
ment. In chapters 9 through 12, treatment approaches are highlighted for
each MUI, which emphasize identifying and managing stressors in the patient's
life. This is crucial, because chronic life stress is a powerful predictor of symp-
tom intensity in MUIs.
The paradigmatic model in health psychology is the biopsychosocial
model. Although universally accepted as the cornerstone for theory and re-
search, a reflexive Cartesian dualism still seeps into much of the discourse on
MUIs. The approach herein attempts to move beyond "either-or" mind-
body labeling and synthesize contemporary theory and research into a better
understanding of the mechanisms through which MUI symptoms occur. This
understanding can then be translated into more effective treatment approaches
for individuals disabled by MUIs.
This volume is intended for health psychologists, clinical psychologists,
gender researchers, physiological psychologists, public health officials, and
medical sociologists. Physicians, nurses, physical therapists, and other medi-
cal personnel, as well as lay people who are affected by these very prevalent
syndromes, can also gain insight into a broader theoretical understanding of
MUI.
MUIs exist in a gray zone between psychiatry and medicine. MUIs tend
to defy efforts to be simplified, just as individuals with MUIs cannot be lumped
into a single category. Early diagnosis and management can help reduce dis-
ability, and integrating psychological treatment into general medical care
will improve the care of patients with MUIs. The treatment evidence pre-
sented in this volume indicates that psychological approaches are generally

6 MEDICALLY UNEXPLAINED ILLNESS

more efficacious than biomedical treatments for MUI. The evidence in this
volume should help psychologists and health care practitioners advocate for
a biopsychosocial approach to patients with MUIs rather than for treatments
guided by dualistic explanations.
Researchers must avoid biological reductionism and examine the con-
tributions of interdependent mechanisms. The complexity of understanding
MUIs calls for more dynamic models to better apportion variance among
multiple factors (Hamilton & Gallant, 1993; Van Houdenhove, Egle, &
Luyten, 2005). This volume presents the evidence for multiple factors and
for the complex and dynamic interaction of biopsychosocial factors that un-
derlie MUIs.

INTRODUCTION
 OVERVIEW OF MEDICALLY
I
UNEXPLAINED ILLNESS

The chronic and disabling medically unexplained illnesses (MUIs) rep-

resent a confluence of multifactorial mechanisms. A complex interaction of
psychological, biological, and socio-environmental factors contribute to a
varied symptom complex. One of the perennial debates surrounding MUIs is
the extent to which they have always been with us. As Simon Wessely (1990)
has asked, are the MUIs "old wine in new bottles"—age-old symptom pat-
terns dressed up with new diagnostic criteria? Certainly there is evidence for
this thesis as explicated in the brief history of MUIs presented in chapter 1.
The labels for MUI vary with the Zeitgeist, but irritable bowel syndrome (IBS),
fibromylagia (FMS), and chronic fatigue syndrome (CFS) have a long his-
tory, whereas a diagnosis of multiple chemical sensitivities (MCS) is more
dependent on exposure to modern chemicals and toxins and thus has a shorter
history. It is important to emphasize the "new bottles" aspect of Wessely's
observation, however. New research presented in this volume suggests that
investigators are gaining more sophisticated understanding of MUIs using
broader conceptual models that include biopsychosocial and person-centered
approaches to MUIs (Masi, White, & Pilcher, 2002).
The question of whether MUIs are somatically disguised psychiatric
disorders is discussed in chapter 2. This chapter connects the high preva-
lence of psychiatric disorders with the etiology of MUIs. Higher symptom
 Biological
Genetics
Sensitization
Hyperalgesia
HPA axis
CNS excitability
Immune
dysfunction

Social
Stress of validation
Physician skepticism
Maladaptive coping
Employment stress
Role strain

Cognitive
Catasttophizing
Amplification
Symptom vigilance
Disease conviction
Somatic attribution

Figure 1. Integrated biopsychosocial model of mutually influential factors of

medically unexplained illness. HPA = hypothalamic-pituitary-adrenocortical;
CNS = central nervous system.

reporting among women is linked to higher rates of depression and anxiety,

and thus an increased likelihood of symptom somatization. Currently, the
MUIs do not fit comfortably into a Diagnostic and Statistical Manual of Mental
Disorders (DSM; American Psychiatric Association, 1952, 1968, 1980, 1994,
2000) framework, although the overlap in symptoms with depression, anxi-
ety, and somatoform disorders is substantial. DSM scholars have been debat-
ing the limitations of the categorical classification system that is the hall-
mark of the DSM (Widiger & Samuel, 2005). It is interesting to note that
criticism of the DSM's approach—that psychiatric syndromes do not repre-
sent distinct categorical etiologies, do not have laboratory markers, and have
high rates of co-occurrence—echo the controversies surrounding classifica-
tion of MUIs. A dimensional framework has been proposed for the not-yet-
published fifth edition of the DSM (Widiger & Samuel, 2005), and it is pos-
sible that MUIs would fit into new dimensional classification systems. MUIs
may represent the extreme end of a continuum of somatic complaints. It is

10 INTRODUCTION TO PART I
debatable whether this advances understanding or just creates a more acces-
sible box into which MUIs can be wedged. What is not debatable is the
interaction of social and cognitive factors with biological sensitivities that
influence symptom perception. The contributions of these factors are ad-
dressed in chapters 3 and 4, with an emphasis on the role of gender.
Chapter 3 makes an argument for sociocultural and cognitive factors as
mediators of MUIs. The key psychosocial explanations include gender ste-
reotypes, role strain, and history of abuse; cognitive explanations include
negative affect, catastrophizing, symptom reporting style, and symptom per-
ception. The biological factors that appear to play an important role in MUIs
include genetic explanations, physiological sensitization, and neuroendocrine
influences on immune system functioning. Past research has primarily de-
scribed gender as a demographic variable rather than a variable that may
directly influence other risk factors. Further research is needed to look more
explicitly at how gender informs the biopsychosocial model.
Figure 1 presents an integrated biopsychosocial model of factors mutu-
ally influencing MUIs that are discussed in great detail in chapters 2, 3, and
4. The relative influence and interaction of these factors varies across indi-
viduals and across different MUIs. Future research is required to address ques-
tions generated by this model: How does gender influence physician skepti-
cism to increase symptom vigilance and disease conviction in MUIs? Biological
sensitization has been shown to be a factor in FMS and IBS; is a similar
sensitization operating in CFS? Is there an underlying factor in autoimmune
disease that would help explain female predominance in MUIs? Does the
stress of working to validate MUIs contribute to interpersonal conflict and
stronger somatic attribution? How can multimodal treatment be effectively
delivered in primary care settings? How can health care providers deliver the
message of the biopsychosocial model effectively to patients to reduce doctor
shopping? Would feminist therapy be more effective than cognitive-be-
havioral therapy? Would disease conviction, somatic attribution, and its
role in doctor shopping be reduced if complementary and alternative medi-
cine approaches were tried ? The model outlined in Figure 1 should gener-
ate many more similar questions for researchers and clinicians. The research
that lays the foundation for these questions is presented in this volume.

INTRODUCTION TO PART I I1
 A BRIEF HISTORY OF GENDER IN
1
MEDICALLY UNEXPLAINED ILLNESS

Mysterious symptoms that confound physicians have been reported for

centuries in various cultures. Any discussion of the history of medically un-
explained illness (MUI) must begin with hysteria. Hysteria was recognized as
a medical condition by early Egyptian and Greek cultures, and references to it
were made in the writings of Hippocrates and Galen. Hysteria has traditionally
been viewed as a women's disease; its literal translation from the Greek is '"wan-
dering womb." Trimble (2004) noted that symptoms similar to those reported
in MUI today, and with a gender-specific etiology, were documented more
than 2,000 years ago in at least two different cultures. The term hysterical be-
came almost "interchangeable with 'feminine' in literature, where it stood for
all extremes of emotionality" (Showalter, 1985, p. 129). Showalter (1985) ar-
gued that the vast repertoire of emotional and physical symptoms ranging
from fits, fainting, vomiting, choking, sobbing, laughing, paralysis, and the
rapid passage from one symptom to another was consistent with the percep-
tion of the lability and capriciousness associated with feminine nature.
Neurotic hysteria has been viewed as either a heroic protest against
Victorian repression or as a pathetic collapse into maladaptive illness (Micale
1995; Smith-Rosenberg, 1985). The Freudian perspective was extremely in-

13
fluential in establishing hysteria as an expression of unconscious conflicts
displayed through bodily symptoms (Breuer & Freud, 1895/1987). Symptoms
served a symbolic function in the world of the Victorian woman. Freud's
female patients became the prototype for the hysterical neurotic, and psy-
choanalysis has even been called the child of the hysterical woman. Because
Freud viewed the repression of sexual impulses to be the source of all neuro-
sis, psychoanalytic treatment was aimed at unearthing this unconscious re-
pression in the hysterical patient. Her bodily symptoms were then expected
to dissipate as she gained insight into her unconscious conflicts.
By the late 19th century, hysteria was often confounded with neuras-
thenia; together they were referred to as the "nervous" disorders. Their symp-
toms could certainly overlap, and both resulted in profound disability. Hys-
teria tended to consist of more dramatic, colorful symptoms, whereas
neurasthenia was characterized by fatigue (Micale, 1995; Oppenheim, 1991).
Becker (2005) argued that the pairing of "nerves" and distress in hysteria, the
'"female" disease, preceded the appearance of neurasthenia, the "American"
nervous disease. Showalter (1985) contended that neurasthenia was a more
attractive form of female nervousness than hysteria, although the two were
not always distinguishable.
Fatigue as a debilitating symptom, first reported in the mid-1800s, was
believed to afflict primarily upper-class women (Shorter, 1993; Wessely, 1991).
These women complained mainly of fatigue and muscle weakness, but pain
was also often a prominent symptom. George Beard, an American physician,
was the first to describe neurasthenia as a distinct clinical category (Beard,
1880). The symptoms of neurasthenia included general malaise, disability,
weakness, poor appetite, neuralgic pains, hysteria, hypochondriasis, avoid-
ance of mental labor, and headaches (Macmillan, 1976). By 1900, neuras-
thenia had become an extremely common diagnosis, although it appeared to
be a "catch-all" category (Shorter, 1993). Neurasthenia was used alternately
as a synonym for general nervousness and evolving psychosis, as the '"male"
equivalent of hysteria, as a synonym for minor depression, and as a diagnosis
for unexplained fatigue states (Shorter, 1993; Torres-Harding & Jason, 2005).
Showalter (1985) described neurasthenia patients as women who lan-
guished with fatigue and who were often incapable of any purposeful activity
or of even rising from bed. Although she acknowledged the occurrence of
the illness in men, the main thrust of her argument was that it arose in women
as a form of protest against their empty and unfulfilled lives. Primary sources
reveal contradictory views on the gender distribution of neurasthenia. Some
writers saw it as a disease of professional and intellectual men, leaders, and
captains of industry (Pritchard, 1905). However, some believed that women
were more vulnerable owing to their "weaker nervous systems." Medical
texts of the late 1800s contained comments indicating that young women
were much more prone than young men to nervous complaints. They also
voiced the common concern that educating women could contribute to ner-

14 MEDICALLY UNEXPLAINED ILLNESS

vous symptoms and damage women's reproductive capacities (Oppenheim,
1991).
Although neurasthenia was diagnosed in both men and women, phy-
sicians perceived numerous differences related to symptoms, causes, and
treatments (Becker, 2005). Beard (1880) made the distinction between male
"cerebrasthenia" brought on by mental overwork and female "myelasthenia"
brought on by physical or emotional shocks. The rest cure was more often
applied to women, whereas men were more likely to be instructed to build
up their energy reserves through vigorous exercise. Gender was an impor-
tant factor in diagnosis; physicians were loathe to diagnose hysteria in men
because it was considered a "feminizing"' label, implying weakness and
vulnerability.
Over time, diagnoses of hysteria and neurasthenia declined as they came
to be redefined as psychiatric because of the stigma of psychiatric labels
(Wessely, 1991). Within the medical profession, the development of psy-
choanalysis and the increase in psychological treatments all but eliminated
the diagnosis of disorders that were a physical expression of distress (Swartz,
Blazer, George, & Landerman, 1986). Shorter (1992) argued that the de-
creased prevalence of neurasthenia was due to a paradigm shift in medicine
in which neurasthenic symptoms came to be regarded as psychological.
Somatizing patients therefore selected symptoms that were more likely to be
construed as organic from the "symptom pool." As people became more psy-
chologically literate, they understood the psychodynamics behind "nervous"
symptoms. Then, as now, psychological symptoms were seen as less legiti-
mate than organically based ones.
Micale (1995) argued that as society progressed away from Victorian
strictures on women, escape into illness became less necessary. It has been
acknowledged that hysteria and neurasthenia may have acted as symbols for
women's restricted opportunities (Showalter, 1985; Smith-Rosenberg, 1985).
The emancipation of women and the liberation of sexual attitudes were im-
portant in decreasing women's need to express themselves somatically
(Showalter, 1985; Smith-Rosenberg, 1985). It is interesting that today's dis-
cussions of MUI rarely link women's current role requirements to burgeon-
ing rates of MUIs.
Neurasthenia and hysteria were diagnosed less frequently as more work-
ing class people began to suffer from them. New research has indicated that
symptoms of hysteria and neurasthenia were not rare among the working
classes but that the conditions were unrecognized, untreated, and
underreported (Micale, 1995; R. Taylor, 2001). This is similar to the case
of chronic fatigue syndrome (CFS), which was originally labeled "yuppie
flu" until several community-based epidemiological studies showed that
higher levels of fatigue were found among non-White minority groups (Song,
Taylor, & Jason, 1999; Steele et al, 1998), and the yuppie label became
obsolete.

A BRIEF HISTORY OF GENDER IN MEDICALLY UNEXPLAINED ILLNESS 15

 The first Diagnostic and Statistical Manual of Mental Disorders (DSM;
American Psychiatric Association, 1952) had several categories for Hyste-
ria: by symptom, conversion disorder, and personality trait ("Emotionally
Unstable Personality"). The second edition of the DSM (DSM-II; American
Psychiatric Association, 1968) further categorized hysteria as "Hysterical
Neurosis" (conversion reaction and dissociative reaction) and "Hysterical
Personality." In the third edition of the DSM (DSM-III; American Psychiat-
ric Association, 1980), the term Hysterical Personality was replaced with His-
trionic Personality Disorder to emphasize the histrionic behavior pattern and
to reduce the confusion caused by the historical links of hysteria to conver-
sion symptoms. Hysterical Neurosis, Conversion Type became Conversion Dis-
order. The third revised edition of the DSM (DSM-III-R; American Psychi-
atric Association, 1987) retained the term Histrionic Personality Disorder, but
the criteria for it were revised. The fourth edition of the DSM (DSM-IV;
American Psychiatric Association, 1994) includes the classification
Somatoform Disorders, which includes Conversion Disorder, and it still re-
tains Histrionic Personality Disorder.
The history of neurasthenia in the DSM is equally convoluted. Neuras-
thenia did not appear in the original DSM; it appeared in DSM-II, but it was
summarily dropped in DSM-III. It reappeared in DSM-IV in the appendices
as a culture-bound syndrome. The core symptoms of neurasthenia were de-
scribed in DSM-IV as persistent mental or physical fatigue accompanied by
at least two of seven symptoms: dizziness, dyspepsia, muscular aches or pains,
tension headaches, inability to relax, irritability, and sleep disturbance. Ex-
clusion criteria were described as mood or anxiety disorders.
Some have argued that neurasthenia has not disappeared but that the
symptom complex was first subdivided into various neuroses, including
obsessive-compulsive disorders, anxiety neuroses, and hysterical personality
(Shorter, 1992), and more recently as CFS, fibromyalgia (FMS), multiple
chemical sensitivities (MCS), and various other MUIs (Ford, 1997; Micale,
1995; Wessely, 1996). Neurasthenia is still included in the latest revision of
the International Classification of Diseases, 10th Revision (World Health Orga-
nization, 1992), and it is still diagnosed in parts of Europe, Russia, and Asia,
where it is seen as a physical disorder (P. Y. Schwartz, 2002; Wessely, 1991).
In the 1970s, a variant of hysteria apparently began to be diagnosed as
a psychiatric disorder called Briquet's syndrome. First described by a French
psychiatrist in 1859, Briquet's syndrome was formally defined by Guze, Woo-
druff, and Clayton (1971) as a subtype of hysteria occurring predominantly
in women with a complicated and dramatic medical history beginning before
age 30. Briquet's syndrome consists of the presence of a minimum of 25 medi-
cally unexplained symptoms in at least 9 of 10 symptom groups (Guze, 1975);
it is found to be a reliable and valid diagnosis (Guze, Cloninger, Martin, &
Clayton, 1986). Briquet's syndrome is associated with familial aggregation in
women but not in men (Cloninger, Martin, Guze, & Clayton, 1986).

16 MEDICALLY UNEXPLAINED ILLNESS

 Liskow, Othmer, Penick, DeSouza, and Gabrielli (1986) found that fe-
male psychiatric outpatients with Briquet's syndrome had an average of 4.3
other psychiatric syndromes. These disorders include depression, panic, pho-
bia, obsessive-compulsive disorder, antisocial personality disorder, and sub-
stance abuse. Liskow et al. suggested that Briquet's syndrome patients have a
response bias and answer yes to many questions regarding psychopathology
just as they do to questions relating to medical symptoms. Support for the
sheer multiplicity of complaints in Briquet's was also found by Wetzel, Guze,
Cloninger, Martin, and Clayton (1994). They compared women with pri-
mary affective disorder with women with Briquet's syndrome on the Minne-
sota Multiphasic Personality Inventory. The women with Briquet's syndrome
reported more complaints of all types in all areas than depressed women,
even after controlling for response bias. Wetzel et al. concluded that women
with Briquet's syndrome present with multiple somatic and psychological
symptoms. Orenstein (1989) proposed that Briquet's syndrome represents
the most extreme expression of a tendency for the aggregation of physical
symptom reporting, depression, panic disorder, and agoraphobia.
In DSM-III, Briquet's syndrome surfaced as somatization disorder; the
criteria for identifying it were simplified and fewer symptoms were required
for diagnosis. Thus, one could argue that hysteria has evolved into the
somatoform disorders. Rief and Sharpe (2004) observed that the medical
community rarely uses the term somatoform disorder. Rather, every medical
specialty has its own MUI syndrome: gastroenterology has irritable bowel
syndrome, rheumatology has FMS, gynecology has pelvic pain syndrome, and
so on. Rief and Sharpe argued that a general label such as medically unex-
plained symptoms or functional somatic syndromes, although not ideal, is re-
quired, because separate MUI categories are not sufficiently distinct, and
their similarities outweigh their differences.
The symptom of fatigue is a good example of a commonly occurring
symptom in MUIs that has garnered different taxonomy throughout history.
Shorter (2005) charted the rise and fall of fatigue as a psychiatric symptom.
In the first edition of the DSM, which appeared in 1952, general fatigue
was listed as the chief symptom in the condition "psychophysiologic ner-
vous system reaction." In DSM-II, published in 1968, the term neurasthenic
neurosis (neurasthenia) was introduced as an official diagnosis. Also added
was a seldom-used diagnosis, asthenic personality, characterized by easy fati-
gability. In DSM-III, American psychiatry thus relegated fatigue to the level
of one of many symptoms required to meet criteria for various affective disor-
ders. The former asthenic personality was collapsed into "dependent person-
ality disorder."
As fatigue faded from psychiatric taxonomy, it started to become epi-
demic in physicians' offices (Shorter, 2005), perhaps because it was perceived
as a physical symptom without the stigma associated with asthenia. In the
1980s, patients began attributing feelings of chronic weariness and chronic

A BRIEF HISTORY OF GENDER IN MEDICALLY UNEXPLAINED ILLNESS 17

pain to infection by Epstein-Barr virus. Shorter (2005) contended that this
epidemic differed from other similar epidemics across the ages by the tenac-
ity of patients' belief in a particular pathogen. Although Epstein-Barr virus
was soon discredited scientifically as the cause of fatigue symptoms, the diag-
nosis of CFS or myalgic encephalitis took hold, purported to be the conse-
quence of a breakdown in the immune system or a viral infestation (Shorter,
1992, 2005; Wesselv, 1990).
Torres-Harding and Jason (2005) summarized the view of many mid
20th century physicians who espoused a holistic approach to fatigue and
emphasized the need to take into account physical factors, such as infection
or overwork, in addition to psychogenic or personality factors. Several out-
breaks of illnesses with fatigue as a chief or principal symptom and with un-
known etiology were also reported (Levine, 1994; Wessely, 1991). These
unexplained fatigue illnesses were given multiple labels, including epidemic
neuromyasthenia, myalgic encephalomyelitis, Iceland disease, and atypical polio-
myelitis.
In addition to neurasthenia, other unexplained illnesses were reported
in the late 19th and early 20th century. Some of these illnesses were called
effort syndrome, disordered action of the heart, and neurocirculatory asthenia.
T. Lewis (1940) first described effort syndrome, the symptoms of which in-
cluded breathlessness, pain, palpitation, fainting, giddiness, headaches (es-
pecially after exertion), and complaints of fatigue (summarized by Torres-
Harding & Jason, 2005). Initially, these disorders were regarded as arising
from anomalies of cardiac function. Over time, however, as efforts to find
underlying physiological abnormalities were not successful, these illnesses
began to be regarded as primarily psychosomatic in nature.
Feinstein (2001) described a number of syndromes that have affected
soldiers since the Crimean War. Among the names given to these syndromes
were DaCosta syndrome (DaCosta, 1871); soldier's heart; shell shock; combat
stress; neuocirculatory neurasthenia; and most recently, Gulf War syndrome. A
syndrome akin to fibromyalgia was described by Cowers (1904) as fibrositis,
marked by tenderness in a number of body regions that was not accompanied
by tissue inflammation. Later, disturbed sleep, particularly a deficit in deep
sleep, and exhaustion were part of the syndrome (Smythe, 1989). The term
fibrositis was widely used until the American College of Rheumatology devel-
oped the criteria for FMS in 1990.
Multiple chemical sensitivity emerged as a descendant of food allergy
problems, which were described in the 1920s and 1930s, when theorizing about
sensitization to low levels of chemicals was set in the framework of allergy.
Concerns about food allergies were transferred to the environment more broadly
by the 1960s, when the term chemical sensitivity began to be used, and the clini-
cal definition was developed in the 1980s (Shorter, 1992, 1997).
Many individuals report a complex mix of somatic and psychological
symptoms that belie discrete categorization (Hickie, Hadzi-Pavlovic, & Ricci,

18 MEDICALLY UNEXPLAINED ILLNESS

1997). MUIs have always challenged traditional perspectives on illness. Al-
though the lack of definitive pathophysiology is frustrating, there do appear
to be subtle physiological abnormalities in most MUIs (S. K. Johnson, DeLuca,
&Natelson, 1999). Some have argued that many of Freud's classic "hysteria"
cases were likely suffering from undiagnosed neurological disorders (Webster,
1995). Slater and Glithero (1965) asserted that in a group of patients diag-
nosed with hysteria in the 1950s, 33% actually suffered from serious organic
disease. Increases in medical sophistication have significantly reduced the
number of inaccurate hysteria diagnoses, but prognosis for chronic symptoms
remains poor (Mace & Trimble, 1996). Stone et al. (2005) systematically
reviewed 27 studies done since 1965 that had median follow-up durations of
5 years and included a total of 1,466 patients. Misdiagnosis was considered to
have occurred when investigators concluded that most of a patient's original
symptoms or signs were subsequently explained by disease. The average rate
of misdiagnosis in these later studies was only 4%, which led the researchers
to conclude that most medically unexplained symptoms were rarely misdiag-
nosed in contemporary investigations.
R. Taylor (2001) noted that a core cluster of nonspecific unexplained
symptoms can be identified in historical case records and have continued to
be reported by a significant proportion of individuals seeking medical treat-
ment over the past 2 centuries. The diagnostic categories for these unex-
plained symptoms have fluctuated over time, with a shift in the 20th century
to psychological diagnoses. Patients with unexplained physical symptoms have
suffered considerably and have been passed to and fro between medical doc-
tors and psychiatrists (Shorter, 2005).
This brief history conveys some of the similarities among hysteria, neur-
asthenia, and contemporary MUI. A number of theorists (Barsky & Borus,
1999; Feinstein, 2001; Shorter, 1992; Showalter, 1997; Wessely, 1991) have
argued that MUIs are modern, media-driven forms of hysteria resulting from
a stressed-out, exhausted populace unwilling to accept their symptoms as
emotionally caused. They contend that the Zeitgeist of the times and a quest
for organicity determines the pattern of symptoms displayed. Ford (1997)
went so far as to call MUIs "nondiseases" and stated that "hysteria is alive
and well, and one contemporary hiding place is fashionable illness" (p. 7).
Ford claimed that certain diagnoses were fashionable, namely MCS, FMS,
reactive hypoglycemia, repetitive strain injury, and CFS. This skeptical view
was echoed by Shorter (1997), who contended that MCS was the latest in a
line of "pseudodiseases" that started with hypoglycemia in the 1960s and
1970s and was replaced by CFS and fibrositis in the 1980s and repetitive
strain injury and sick building syndrome in the 1990s.
The view of MUI as shaped by the media Zeitgeist, the Internet, and
peer groups is somewhat overstated. Furthermore, such arguments can
heighten the divisions between MUI advocates and the medical community.
There is no doubt that the culture plays a role in shaping symptoms and

A BRIEF HISTORY OF GENDER IN MEDICALLY UNEXPLAINED ILLNESS 19

labeling syndromes (Gureje, 2004). Additionally, economic factors may
motivate patients to be more inclined to present with physical symptoms,
because insurance reimbursement for psychiatric treatment is substantially
lower than for physical illness treatment. Some would argue that MCS is
an entirely socially constructed illness because it exists only in certain coun-
tries (Zavestoski et al., 2004). Yet, there are several important distinctions
between 19th-century interpretations and contemporary ones. Today's level
of medical sophistication makes medical diagnosis more accurate and effi-
cient, which means that fewer symptoms are unexplained. Moreover, tech-
nological advancement and knowledge of molecular biology, biochemistry,
infectious microbiology, and neurophysiology has helped advance the un-
derstanding of interactions between mind and body such as the stress/
hypothalamic-pituitary-adrenal axis connection.
A biopsychosocial model posits that culture may influence symptom
reporting and that there is also a bidirectional influence between brain physi-
ology and symptoms. Katon, Sullivan, and Walker (2001) gave the example
of irritable bowel syndrome, in which changes in brain physiology secondary
to stressful events can cause abnormalities in smooth muscle tone in the gut
and that these gut abnormalities are also associated with changes in brain
physiology. Thus, cultural, psychosocial, and cognitive processes can become
dominant in a vulnerable biological system.

20 MEDICALLY UNEXPLAINED ILLNESS

 2
PSYCHIATRIC DISORDER IN
MEDICALLY UNEXPLAINED ILLNESS

Many symptoms people experience cannot be explained by an estab-

lished medical condition. Seventy percent of people with symptoms who
visit primary care doctors leave without a diagnosis or treatment plan (Kroenke
& Harris, 2001). This implies that a huge number of symptoms that bring
people to physicians' offices are unexplained. Although many somatic symp-
toms are self-limited and have a favorable prognosis, about 25% of patients
report persistent, chronic symptoms such as pain, fatigue, and headache
(Kroenke, 2001a, 2001b; Kroenke et al, 1997; Kroenke & Harris, 2001;
Verhaak, Meijer, Visser, & Wolters, 2006). In up to 50% of primary care
visits, no organic cause is found for the presenting symptom, and most pa-
tients do not receive a definite diagnosis (Barsky & Borus, 1995; Kroenke &
Mangelsdorff, 1989). Fink, Rosendal, and Toft (2002) summarized this situ-
ation by stating that it is "the exception rather than the rule in primary care
for physical symptoms to be caused by organ pathology or pathophysiological
disturbances" (p. 99). Many medically unexplained symptoms (MUS) fall
into clusters and have evolved into syndromes. Irritable bowel syndrome (IBS),
chronic fatigue syndrome (CFS), fibromyalgia (FMS), and multiple chemi-

21
cal sensitivity (MCS), the medically unexplained illnesses (MUIs) exam-
ined in this volume, are among the most common.
A perennial topic in the MUI literature is the high prevalence of life-
time and comorbid psychiatric disorders. The most commonly reported of
such disorders are depression, anxiety, and somatization disorder (SD). (So
matization has a number of definitions, but its core characteristic is presenta-
tion of physical symptoms that are not sufficiently explained by medical,
organic findings.) This high prevalence may mean that psychiatric disorders
are a crucial part of the etiology of MUI and that there are many overlapping
symptoms, which suggests a common pathophysiology. Alternately, common
symptoms may be amplified because of psychiatric distress, because a person
with MUI may experience reactive depression to the disability imposed by
MUI, or because physicians may have a tendency toward "psychologizing"
women's symptoms. What is not in dispute is that numerous research studies
have shown high rates of lifetime and current diagnoses of somatoform, mood,
and anxiety disorders among MUIs. The relationship between these psychi-
atric disorders and MUIs and the role of gender is discussed in this chapter.
Strong epidemiological evidence suggests female preponderance in all
of the MUIs (Barsky & Borus, 1999; Kroenke & Spitzer, 1998). All of the
MUIs are diagnosed on the basis of subjective symptom report. Women have
consistently been shown to report higher numbers of symptoms than men.
Most physical symptoms are reported at least 50% more often by women
than by men, and this is not completely explained by higher levels of mental
disorders in women (Kroenke & Spitzer, 1998). Although many studies have
shown higher levels of somatization in women than in men, levels of hypo-
chondriacal concerns are not different between men and women. Women
also do not worry about serious illness more than men do (Barsky & Wyshak,
1990; Creed & Barsky, 2004).
There is no sharp delineation between symptoms of psychiatric disor-
der in MUIs that are clearly psychological and those that are clearly organi-
cally based. Numerous symptoms, such as fatigue, cognitive difficulties, sen-
sitivity to pain, and sleep problems, occur commonly in both psychiatric and
organic conditions. Thus, it is often the health care professional who must
make the distinction between psychological symptoms and organic symp-
toms. S. K. Johnson, DeLuca, and Natelson (1996a) found that designation
of CFS symptoms as organic strongly affects the diagnosis of SD within the
CFS population; if the examiner attributes the patient's CFS symptoms to
physical illness, diagnosis of SD is unlikely. Kirmayer, Robbins, and Paris
(1994) also make the point that the designation of symptoms as unexplained
vacillates, depending on current medical explanations of symptoms.
Although discussing MUIs in the context of SDs is controversial,
somatizing tendencies must be considered when organic findings are insuffi-
cient to explain high levels of disability. MUIs often share a number of char-
acteristics with somatoform disorders in addition to multiple unexplained

22 MEDICALLY UNEXPLAINED ILLNESS

symptoms in a variety of body systems: Doctor shopping, disease conviction,
aversion to psychogenic explanations, and comorbidity with other psychiat-
ric disorders are some of the most common (Bornschein, Hausteiner, Konrad,
Forstl, & Zilker, 2006).
Fink (1996) suggested that MUIs such as CFS and FMS may be arti-
facts of suggestibility in somatizing patients; for example, individuals with
somatizing tendencies grasp onto publicized syndrome criteria to shape their
symptom presentation. Similarly, Barsky and Borus (1995) viewed the in-
crease in MUIs as influenced by sociocultural trends that reduce people's
tolerance for mild symptoms and lower the threshold for seeking medical
care. People amplify and misattribute discomforts to disease, a process that
may be abetted by medical professionals and the media. They call for recog-
nition of the normative presence of symptoms and distress that do not re-
quire medical intervention. In this context, it is interesting to note that men
are more likely than women to make normalizing attributions for somatic
symptoms (see chap. 3, Somatic Attribution section, this volume).

SOMATOFORM DISORDERS AND SOMATIZATION

The behavioral tendency to note and report physical symptoms is
thought to be related to three cognitive traits: selective attention and ampli-
fication of somatic symptoms, a belief that these symptoms are caused by
physical disease, and attempts to seek medical care for symptom relief (Barsky
& Wyshak, 1990; Lipowski, 1988; Whitehead & Palsson, 1998). Kirmayer et
al. (1994) summarized a number of processes that contribute to somatic dis-
tress: neuroticism, individual differences in physiological reactivity, symp-
tom perception, symptom thresholds, somatic attention, coping resources,
and tendencies toward help seeking. Trait anxiety and trait negative affect,
both higher in women, appear to be associated with a cognitive style of height-
ened vigilance toward body sensations (Pennebaker, 1994). Numerous in-
vestigators (Barsky & Borus, 1999; Kirmayer et al., 1994; Kroenke et al.,
1997; Manu, 2004) have made persuasive arguments that somatizing pro-
cesses pervade the MUI, especially in those who seek medical care and medi-
cal validation and are very disabled by MUIs. Gleason and Yates (2002)
have noted that "female gender stands out as the most important risk factor
for somatization" (p. 309). They explained this in terms of the five mecha-
nisms proposed by Wool and Barsky (1994): (a) Somatic symptom reporting
is more culturally approved in women compared with men; (b) women more
readily seek medical care for symptoms than men do; (c) psychiatric disor-
ders that include somatizing tendencies are more common in women than
in men; (d) women have higher rates of childhood trauma than men; and
(e) women have greater sensitivity to bodily sensations than men.
Because so many terms are used to label SD, and because somatization
is often described as a behavior or a process, it is important to remember that

PSYCHIATRIC DISORDER 23
somatization does exist as a Diagnostic and Statistical Manual of Mental Disor-
ders (DSM) classification, albeit a problematic one. According to the fourth
edition of the DSM (DSM-IV; American Psychiatric Association, 1994),
SD is characterized by a lifetime history of multiple medically unexplained
physical symptoms, including at least four unexplained pain symptoms, two
unexplained nonpain gastrointestinal symptoms, one unexplained sexual
symptom, and one pseudoneurological symptom. SD is rarely diagnosed in
men. Most men with somatic complaints have disorders with prominent anxi-
ety symptoms (Cloninger, Martin, Guze, & Clayton, 1986).
Many patients with SD meet criteria for other psychiatric disorders
(Robins et al., 1984; Swartz, Blazer, George, & Landerman, 1986) and incur
very high rates of recurring health care utilization (Barsky &. Borus, 1995;
Hiller & Fichter, 2004; Kolk, Schagen, & Hanewald, 2004; G. R. Smith,
Monson, & Ray, 1986). SD seems to represent the extreme end of a somati-
zation continuum (Allen & Escobar, 2005; Escobar, Bumam, Karno, Forsythe,
& Golding, 1987; Katon et al., 1991; Melville, 1987). To describe individu-
als who do not meet SD criteria, Escobar et al. (1987) introduced the label
abridged somatization for men complaining of at least four unexplained physi-
cal symptoms and women complaining of at least six unexplained physical
symptoms. Abridged somatization is also associated with increased use of
medical services and elevated levels of disability and psychopathology (Escobar
et al., 1987; Katon et al., 1991). Moderate levels of somatization appear to be
widespread in primary care, with the prevalence of abridged somatization in
the population estimated to be 22% (Escobar, Waitzkin, Silver, Gara, &
Holman, 1998).
Fink, Hansen, and Oxhoj (2004) examined prevalence of full-blown
SD in a sample of 294 consecutively admitted general medical inpatients in
Denmark. They found that 18.1% of individuals met International Classifica-
tion of Diseases (World Health Organization, 1992) criteria for a diagnosis of
SD, whereas 20.2% met DSM-IV criteria for SD. SDs were much more preva-
lent among women, and there was a significant trend for female prevalence
to decrease with increasing age.
Other DSM-IV SDs include undifferentiated SD (which would include
most unexplained illnesses), conversion disorder, pain disorder, hypochon-
driasis, and SD not otherwise specified. Creed and Barsky (2004) reviewed
the epidemiology of SD and hypochondriasis in primary care and popula-
tion-based samples. They searched MEDLINE and PsycLIT from 1966 to
2002 and found that only 47 studies fulfilled the inclusion criteria of calcu-
lating a prevalence figure using a standardized definition. They concluded
that population studies do not support the assumption that SD and hypo-
chondriasis are discrete psychiatric disorders. Rather, there is considerable
evidence that these disorders are very closely allied with anxiety and depres-
sive disorders. They also noted that there was a predominance of women
with SD in population and primary care samples. When abridged somatiza-

24 MEDICALLY UNEXPLAINED ILLNESS

tion definitions are used, female predominance drops, underlining the con-
nection between multiple symptom reporting and female gender. Hypochon-
driasis, however, did not seem to show a gender bias. A preponderance of
evidence indicates that women somatize more than men, and women are
diagnosed significantly more frequently with SD (Gijsbers van Wijk & Kolk,
1997; Gleason & Yates, 2002).
Research has consistently shown that the number of unexplained symp-
toms is linearly associated with psychological dysfunction. Hotopf,
Wadsworth, and Wessely (2001) addressed this issue directly in a case con-
trol study using a national birth cohort sample. They found that 955 out of a
sample of 3,262 people were identified as having probable psychiatric disor-
der. On a separate question, 43% of these people acknowledged the presence
of psychiatric disorder; compared with the nonacknowledging group,
acknowledgers were found to be more likely to be female, more educated,
have more severe psychiatric disorder, and report more physical symptoms.
Thus, reporting multiple physical symptoms does not appear to act as a de-
fense against psychiatric disorder diagnosis or acknowledging psychiatric dis-
order. Yet it is clearly related to psychiatric disorder.

Dualism and Somatization

Does labeling behavior as somatizing set up a false dualism wherein

somatization is not a useful concept? The myriad problems and contradic-
tions inherent in the SD classification of the DSM have been cogently ad-
dressed by Mayou, Kirmayer, Simon, Kroenke, and Sharpe (2005), who call
for an abolition of the SD category from the DSM-IV. MUIs are the epitome
of what is wrong with the SD diagnosis. In its current form in DSM-IV,
classification of SD stigmatizes patients, is overtly dualistic, overlaps with
depression and anxiety in many shared symptoms, is unreliable, lacks a de-
fined threshold, and has unclear medico-legal status. Mayou et al. (2005)
gave the example of IBS as a disorder that could be diagnosed as an undiffer-
entiated Axis I SD as well as an Axis III general medical condition. Clearly,
this is an untenable position. More broadly, McWhinney, Epstein, and Free-
man (1997) criticized the label somatization as a product of Western medicine's
dualistic perspective. In many other cultures, the idea that emotions can be
embodied physically is overtly accepted, and a biopsychosocial model is im-
plicitly accepted.

Associations Among Depression, Anxiety, and Somatization

The World Health Organization has documented that depression, anxi-

ety, and somatic complaints are more common among women than men.
These conditions are related to risk factors such as gender-based roles, stres-

PSYCHIATRIC DISORDER 25
sors, and negative life experiences. The World Health Organization report
(2007) described gender-specific risk factors such as gender-based violence,
socioeconomic disadvantage, low or subordinate social status, and constant
care of others. These risk factors constitute a psychological burden that
have the potential to be expressed in depression, anxiety, or somatization
symptoms.
R. C. Smith et al. (2005) set out to determine the prevalence of DSM-
IV somatoform and nonsomatoform disorders in patients with MUS in a com-
munity-based health maintenance organization. Patients with MUS were
those picked from a chart review of 1,646 high utilizers; trained raters as-
sessed documented (severe MUS) and undocumented (mild MUS)
nonorganic disease. Patients who met the criterion for a high proportion of
undocumented and documented nonorganic symptoms were recruited into
the study. Two hundred six patients with MUS averaged 13.6 hospital visits
in the year preceding the study, 79.1% of them were women, and the average
age was 47.7 years. Patients with full or abridged DSM-IV somatoform diag-
noses were labeled "DSM somatoform-positive," whereas those without such
diagnoses were labeled "DSM somatoform-negative." R. C. Smith et al. found
that 60.2% had a nonsomatoform DSM-IV diagnosis, primarily anxiety or
depression. Only 4.4% had any full DSM-IV somatoform diagnosis, and only
18.9% had abridged SD. Thus, depression and anxiety characterized MUS
patients better than the somatoform disorders. Correlates of DSM somatoform-
negative status were female gender and less severe psychiatric and physical
dysfunction. These data suggest that multiple unexplained symptoms are not
the same as SD, are more closely related to depression and anxiety, and are
more common in women.

MOOD AND ANXIETY DISORDERS IN

MEDICALLY UNEXPLAINED ILLNESSES

The majority of patients with depression and anxiety who go to primary

care physicians do not present with psychological symptoms but rather with
somatic symptoms such as fatigue, pain, headache, gastrointestinal complaints,
and disturbed sleep (Kroenke, 2001). Patients with MUIs in both primary
care and medical specialty samples have significantly higher rates of depres-
sion and anxiety than do comparable patients with clearly defined medical
diseases (Katon, Sullivan, & Walker, 2001; Wessely, Nimnuan, & Sharpe,
1999). In a comprehensive meta-analysis, Henningsen, Zimmerman, and
Sattel (2003) examined the relationship between MUIs (FMS, CFS, IBS,
and nonulcer dyspepsia) and anxiety and depression. They reviewed 244 stud-
ies and concluded that depression and anxiety are a common feature of these
MUIs. The association with depression and anxiety is higher than in healthy
controls or in patients with similar symptoms explained by a medical diagno-

26 MEDICALLY UNEXPLAINED ILLNESS

sis. Compared with patients with IBS, patients with FMS were significantly
less anxious and patients with CFS were significantly more depressed.

Depression, Anxiety, and Gender

It is well established that anxiety and depression have a higher preva-

lence among women than among men and that these conditions are also
strongly related to symptom reporting (Wool 6k Barsky, 1994). One might
reasonably ask whether the higher rate of MUIs in women can be explained
by their higher rates of depression and anxiety. The data do not support this
parsimonious explanation, however. Haug, Mykletun, and Dahl (2004) ex-
amined the association between anxiety, depression, and somatic symptoms
in a large population-based study of all inhabitants in a Norwegian county
who were 20 years old or older. The association between anxiety and depres-
sion and number of functional somatic symptoms was found to be strong, and
it was as strong among men as among women, although women consistently
reported more symptoms.
Likewise, Kroenke and Spitzer (1998) assessed whether gender dispari-
ties in symptom reporting were attributable to psychiatric comorbidity in the
PRIME-MD 1000 study. Although physically unexplained symptoms were
more frequent among women, and depressive and anxiety disorders were the
strongest correlate of symptom reporting, gender had an independent effect
that persisted even after adjusting for psychiatric comorbidity. Thus, women's
tendency to report more unexplained symptoms is not solely explained by
women's higher rates of depression and anxiety.
Women with unipolar depression outnumber men 2:1. The gender dif-
ference in depression is robust, with a female preponderance in prevalence,
incidence, and morbidity risk for major depression, dysthymia, atypical de-
pression, and seasonal affective disorder (Piccinelli & Wilkinson, 2000). A
consistent factor that differentiates female and male depression is the pre-
ponderance of somatic symptoms in female depression. Women are much
more likely than men to report depression with appetite loss, sleep distur-
bances, and fatigue, but they are not more likely than men to report depres-
sion without these symptoms (i.e., "pure depression"; Silverstein, 2002). In a
study of 201 opposite-sex twin pairs in which both twins fulfilled DSM-III-
R criteria for major depression, the female twins reported significantly more
fatigue, hypersomnia, and psychomotor retardation than their male twins
(Khan, Gardner, Prescott, 6k Kendler, 2002). In an international study of 14
countries, females in all of the centers were twice as likely to report more
somatic symptoms than men (Maier et al., 1999). Thus, it is well established
that higher levels of somatic symptoms do characterize depression among
women.
In a review of gender differences in depression, several social factors
were found to contribute to the higher incidence of women among depressed

PSYCHIATRIC DISORDER 27
individuals. These factors included adverse events in childhood, depression
and anxiety disorders in childhood and adolescence, crises involving chil-
dren and housing, reproductive problems, and poor coping skills (Piccinelli
& Wilkinson, 2000). Girls are more likely than boys to be victims of sexual
abuse in childhood, which may contribute to their greater risk for depression
and anxiety disorders (Weiss, Longhurst, & Mazure, 1999).
Women are more likely to use a ruminative response style, dwelling on
negative events and focusing on their symptoms and the possible causes and
consequences of their symptoms. People who ruminate show longer lasting
depressions than people who take action to distract themselves from their
symptoms (Nolen-Hoeksema, Larson, & Grayson, 1999). Ruminative re-
sponses prolong depression because they allow the depressed mood to nega-
tively bias thinking and interfere with coping behavior. This rumination may
extend to health problems. In a series of studies, Silverstein and colleagues
(Silverstein & Blumenthal, 1997; Silverstein, Caceres, Perdue & Cimarolli,
1995; Silverstein & Lynch, 1998) found that anxious, somatic depression
(but not pure depression) in adolescent girls was associated with distress over
the achievement and occupational limits experienced by their mothers.
Klonoff, Landrine, and Campbell (2000) found that in a sample of 255
university students, women scored higher on anxiety, depression, and soma-
tization symptoms than men. Critically, women with low exposure to sexist
stress did not differ from men on these symptoms, whereas women with fre-
quent exposure to sexist stress accounted for the gender difference in symp-
toms. These findings were not explained by ethnicity, marital status, educa-
tion or income differences, or reporting bias. Klonoff et al. hypothesized that
an accumulation of stress contributes to women's symptoms of depression,
anxiety, and somatization. Because women experience gender-specific stres-
sors that men do not (e.g., discrimination, battering, and sexual harassment),
women exhibit more symptoms because they experience more stress.
Gender-related stress, as well as rumination about that stress, appears to be
related to depression, anxiety, and somatization.

Gender, Depression, and Pain

Gender may moderate the relationship between distress and pain. Find-
ings in this area have been inconsistent; some studies have found that de-
pression among women is associated with greater pain-related disability and
that anxiety is related to greater pain severity in men, whereas other studies
find no gender differences (Keogh, McCracken, & Eccleston, 2006). Keogh
et al. (2006) examined whether gender moderated the relationship between
anxiety and depression and pain and pain-related disability in 260 patients
enrolled in a British pain management center. When depression was high,
women reported greater disability than men, whereas men took more medi-
cations than women. Social gender roles may be operating here, with women

28 MEDICALLY UNEXPLAINED ILLNESS

having a stronger belief in the link between depression and pain than men,
thus rendering women more vulnerable to disability. We know that health
care practitioners are more likely to prescribe antidepressants and antianxi-
ety drugs for women than men, even for similar symptoms (Hohmann, 1989).
Women are also more likely to make psychologizing attributions for symp-
toms, whereas men are more likely to make normalizing attributions (Nykvist,
Kjellberg, & Bildt, 2002).

Depression and Anxiety in Medical Illness

Medical patients generally report higher rates of depression and anxi-

ety than matched healthy controls. Some of this may be attributable to con-
founding of symptoms. There is ample evidence that somatic symptoms can
artificially elevate depression levels in a variety of medical populations (Frank
et al, 1992; Nyenhuis et al., 1995; Plumb & Holland, 1977; A. Williams &
Richardson, 1993). Yet the core elements of depression, such as negative
self-evaluations, depressed affect, and suicidal ideation, are lower in many
medical populations than those seen in clinical depression. The high rates of
depression and anxiety in MUIs may also be partially explained by confound-
ing of symptoms on self-report and interview surveys. Symptoms such as fa-
tigue, pain, difficulty concentrating, difficulty sleeping, loss of appetite, and
excessive health worry can be part of a psychiatric assessment of depression
or anxiety but are also common in medical illness. In a study that specifically
examined depressive symptoms in CFS, S. K. Johnson, DeLuca, and Natelson
(1996b) found that although individuals with CFS may meet criteria for de-
pressive disorder or score in the depressed range on a self-report inventory,
they had significantly higher somatic and significantly lower self-reproach
scores than a clinical depressed comparison group. It may be more than a
confounding of symptoms and closer to a common pathophysiology, how-
ever. In a review of mood disorders in medical illness, Evans et al. (2005)
posited that a growing body of evidence indicates that biological mecha-
nisms underlie a bidirectional relationship between depression and many
medical conditions.
Simple explanations seem to elude us yet again. Clearly the high rates
of depression and anxiety in individuals with MUIs are not just a reporting
artifact of confounding symptoms and may be more than a reaction to dis-
ability wrought by illness. Lifetime history of depression and anxiety is higher
among individuals with MUIs than among those with comparable medical
diseases. Individuals with similar symptoms caused by medical disease have
higher psychiatric morbidity than healthy people, but they have consistently
lower levels of psychiatric distress than their counterparts with MUIs.
Rief, Martin, Klaiberg, and Brahler (2005) surveyed a representative
German sample of 2,507 people and identified those with panic disorder,
somatic syndrome, and depression on the Scale for the Assessment of Illness

PSYCHIATRIC DISORDER 29
Behavior (Rief, Ihle, & Pilger, 2003). Those with panic disorder showed the
highest scores for illness behavior and health care use. Depression was associ-
ated with illness consequences (e.g., '"Illnesses influence the way I act to-
ward family and friends") and illness expression (e.g., "Everyone can see when
I am suffering"). People with somatic syndromes had the highest scores on
medication and treatment (i.e., relied on and had confidence in pharmaco-
logical treatment) and scanning the body for symptoms. This study illus-
trates the connection between mood and anxiety disorders and greater ill-
ness expression and health care utilization—the intimate connection that
often exists between psychiatric morbidity and multiple somatic symptoms.
The presentation of multiple somatic symptoms also can mean an individual
meets criteria for several MUIs concurrently, which leads to the issue of overlap
among the MUIs.
The tendency for substantial overlap among the various MUIs rein-
forces the view that these disorders involve somatization. Numerous investi-
gators have noted this overlap—that is, individuals with one of these condi-
tions are more likely to have another of these conditions (Aaron & Buchwald,
2001, 2003; Barsky & Borus, 1999; Buchwald & Garrity, 1994; Clauw, 1994,
2001; Clauw & Chrousos, 1997; Deary, 1999; Hudson & Pope, 1989; Manu,
2004; Peres, 2003; Wessely et al., 1999; Whitehead, Palsson, & Jones, 2002;
Yunus, 2001, 2002). Specifically, the tendency to report a history of any one
unexplained symptom is associated with a tendency to report many others
(Deary, 1999). Additionally, those who seek care for MUIs are more likely to
have overlapping conditions than those identified within population-based
studies.

CONCLUSION

There are numerous reasons why women have more MUIs. It is well
established that women generally report more symptoms than men. Women
appear to somatize more than men. Women have higher rates of depression
and anxiety, which increase symptom reporting. This chapter has shown that
somatization, depression, and anxiety commonly co-occur in MUIs. It ap-
pears, however, that psychiatric disorder is neither necessary nor sufficient to
explain MUIs. Although the higher prevalence of somatization, depression,
and anxiety in women undoubtedly contributes to their greater prevalence
of MUIs, it is just one piece of the biopsychosocial puzzle. Further pieces of
the puzzle are discussed in chapters 3 and 4.

30 MEDICALLY UNEXPLAINED ILLNESS

 PSYCHOSOCIAL AND COGNITIVE
3
FACTORS IN MEDICALLY
UNEXPLAINED ILLNESS

The biopsychosocial model of illness is premised on the well-established

fact that psychosocial, contextual, and cognitive factors play a major role in
the experience of symptoms. A number of psychological factors may contrib-
ute to gender differences in medically unexplained illnesses (MUIs). Some
of the factors examined in this chapter are lowered thresholds for symptom
perception and reporting, health care utilization, and the effects of gender
roles and expectations on illness behavior. Compared with men, women may
accumulate more stressful experiences such as abuse, have differing beliefs
and attributions for symptoms, and use different coping styles.
There are many potential psychosocial explanations for the higher preva-
lence of MUI in women. The sick role is generally more accepted in women
because gender role stereotypes promote the notion that women are more
delicate and weaker than men. Evidence suggests that women who have strong
feminine gender role identification have more MUIs (Ali, Richardson, &
Toner, 1998; Toner, 1995; Toner & Akman, 2000). Illness behavior, emo-
tional expression, and attributional style can be affected by gender roles.
Women experience more childhood abuse and other stressors, which are as-

31
sociated with higher numbers of unexplained symptoms. Higher rates of child-
hood abuse can lead to hypervigilance regarding physical symptoms and the
perception of symptoms as threatening. Additionally, unexplained symptoms
may be a way to seek care through the medical system.

ILLNESS BEHAVIOR

Mechanic (1972) introduced the term illness behavior to describe the

observation that people with the same illness display a spectrum of illness
behaviors. Illness behavior encompasses characteristics such as health care
use, taking medications, work disability, avoiding activity, expression of symp-
toms to significant others, and doctor shopping. Pilowski (1969) coined the
term abnormal illness behavior to describe behaviors such as having a hypo-
chondriacal attitude and multiple somatic complaints, engaging in inappro-
priate treatment seeking, and displaying disability disproportional to physi-
cal findings. Illness behavior is only moderately associated with illness severity.
Compared with men, women engage in more illness behavior, spend more
days in bed, restrict more of their activities because of illness, and use more
prescription drugs (Kandrick, Grant, & Segall, 1991).
The concept of illness behavior is clearly relevant for the MUIs, wherein
disability levels appear in excess of organic pathology. A similar concept, the
sick role, refers to adopting behaviors such as staying in bed, restricting activi-
ties, and taking medications on their own initiative rather than having them
prescribed by medical professionals. Playing the sick role is generally permit-
ted in those diagnosed with medical conditions, but Western society does
not easily give people permission to be ill in the absence of recognized dis-
ease (Nettleton, 2006).

Learned Illness Behavior

Excessive illness behavior may have its origins in childhood learning

experiences. Children may imitate illness behavior modeled by parents. Al-
ternately, adults with excessive illness behaviors may have had stressful ex-
periences as children, such as early separation or loss of a parent or illness-
specific stressors like hospitalization. Secondary gains may also be operating
in some contexts. Whitehead, Winget, Fedoravicius, Wooley, and Blackwell
(1982) found that patients with irritable bowel syndrome (IBS) reported that
their parents were more likely to give them special attention, foods, or treats
when they were sick compared with healthy controls or patients with peptic
ulcers.
Levy et al. (2004) interviewed 208 mothers with IBS and their 296
children and 241 healthy mothers (controls) and their 335 children. Factors
assessed were stress, mothers' and children's psychological symptoms,

32 MEDICALLY UNEXPLAINED ILLNESS

children's perceived competence, and pain coping style. Children of women
with IBS reported more frequent stomachaches and nongastrointestinal symp-
toms, made more physician visits for gastrointestinal symptoms, had more
nongastrointestinal clinic visits, and missed more school than control chil-
dren. Children whose mothers made solicitous responses to illness complaints
independently reported more severe stomachaches, and they also had more
school absences for stomachaches, but solicitous behavior did not signifi-
cantly impact nongastrointestinal symptom reporting, clinic visits, or school
absences.
To rule out the possibility that children were imitating their parents'
illness behavior, Crane and Martin (2004) looked at mothers of infants
younger than 18 months. They compared mothers taking medication for func-
tional gastrointestinal symptoms (mostly IBS) with mothers with stomach
ulcers, who completed questionnaires when their children were 6 and 18
months old. The infants of mothers with IBS were taken to the doctor for a
significantly greater number of symptoms than were children whose mothers
had ulcers. The mothers did not differ on psychiatric distress variables. This
finding provides evidence for potential reinforcement of illness behavior in
childhood experiences, which may increase vulnerability to MUIs in adult-
hood. Studies of these childhood experiences indicate that children of par-
ents with IBS were more likely than children with non-IBS parents to report
secondary gain and to have more symptom reports, health care use, and dis-
ability, suggesting an intergenerational transmission of illness behavior.

Symptom Reporting

It is well established that women report more symptoms than men across
various age spans (Borglin, Jakobsson, Edberg, & Hallberg, 2005; Haug,
Mykletun, & Dahl, 2004; Kroenke & Spitzer, 1998; Tibblin, Bengstsson,
Furunes, & Lapidus, 1990; Verbrugge, 1985, 1989). In a review paper on
gender and symptom reporting, Gijsbers van Wijk and Kolk (1997) con-
cluded that researchers using health surveys and symptom and physician re-
ports found that adult women reported more frequent or more intense symp-
toms, particularly when symptoms were measured in retrospect. It is interesting
to note that most of this review was concerned with reports from healthy,
community-residing individuals. Conversely, when actual disease was present,
men tended to report more symptoms than women.
Researchers conducting large population-based studies found that
women reported more symptoms. In a Norwegian study of both men and
women that included 50,377 women, Haug et al. (2004) reported an average
of 3.8 symptoms in women compared with 2.9 in men. The most common
symptoms reported were tiredness, gastrointestinal symptoms, headache, back
pain, and pain in arms and shoulders. Tibblin et al. (1990) studied 30 symp-
toms and their prevalence in different age cohorts in men and women from a

PSYCHOSOCIAL AND COGNITIVE FACTORS 33

Swedish population based study. They found that most symptoms, particu-
larly depression and tension, were more common among women, and this
difference was more pronounced in younger age groups. Higher levels of
symptom reporting do not completely diminish with age, however; in a
study of community-dwelling elderly individuals aged 75 to 99 years, women
had a significantly lower health-related quality of life than men and a sig-
nificantly higher degree of self-reported health complaints (Borglin et al.,
2005).
These studies also make clear that the core symptoms of many MUIs,
such as fatigue, pain, gastrointestinal complaints, and headaches, are present
in very high base rates in the general population (Kroenke, 2001). The gen-
der difference in symptoms is not due to women's more complex reproduc-
tive system, gynecological disorders, or menstrual events. In the U.S. Epide-
miological Catchment Area study, 20 out of 22 nonmenstrually related
symptoms were more common in women; only chest pain and difficulty walk-
ing were more common in men (Kroenke & Price, 1993).
Kroenke and Spitzer (1998) also found that increased symptom report-
ing in women was a generic phenomenon and not restricted to particular
types of symptoms. They assessed gender differences in symptoms and inves-
tigated whether these differences were attributable to psychiatric comorbidity.
They analyzed data from the PRIME-MD 1000 study (1,000 patients from
four primary case sites evaluated with the Primary Care Evaluation of Men-
tal Disorders interview; Spitzer et al., 1994) examining the reporting of 13
common physical symptoms. This study controlled for a lower threshold for
seeking care than is often found in women, because all the individuals in the
PRIME-MD study were seeking health care. After adjusting for depressive
and anxiety disorders as well as age, race, education, and medical comorbidity,
all symptoms except one (sexual problems) were reported more commonly
by women, with statistically significant differences for 10 of 13 symptoms.
Medically unexplained symptoms were also more frequent in women. Gen-
der was the most important demographic factor associated with symptom
reporting, followed by lower education and younger age. Total symptom count
was similar to that found by Haug et al. (2004), with women on average
reporting 1.47 more symptoms than men.

Symptom Perception

Under most circumstances, women report more symptoms than men.

What are some possible explanations for this phenomenon? Hibbard and
Pope (1983) showed that women were more likely to perceive symptoms
than men, that women place a higher value on health, and that women have
a higher preventive orientation than men do. Their study population in-
cluded 1,648 adults between the ages of 18 and 59. Medical record data cov-
ering 7 years of outpatient services were linked with survey data on the re-

34 MEDICALLY UNEXPLAINED ILLNESS

spondents. The findings showed that although women were more likely to
perceive symptoms than men, there was no apparent sex difference in a ten-
dency to adopt the sick role when ill. Gender role factors such as level and
type of role responsibility and concern with health were related to female but
not male symptom reports. Illness orientation variables were related to rates
of medical utilization for both genders. However, it was primarily the greater
perception of symptoms and an interest and concern with health in women
that contributed to sex differences in medical utilization rates.
Several gender factors may influence symptom perception and symp-
tom reporting. Women may have lower thresholds for many sensations. There
is evidence that women have lower perceptual thresholds and sensitivity
(Dalton, Doolittle, & Breslin, 2002; Else-Quest, Shibley Hyde, Hill Gold-
smith, & Van Hulle, 2006). Wool and Barsky (1994) have argued that women
are more sensitive to sensations.
Pennebaker (1994) summarized a series of laboratory and field studies
noting consistent gender differences in how individuals perceive and react to
symptoms. His studies have found that women are particularly sensitive to
situational and environmental cues, whereas men are more sensitive to in-
ternal physiological cues. In controlled laboratory studies, men are more ac-
curate at detecting heart rate, stomach activity, blood pressure, and blood
glucose levels. In field studies or in the home, there are no gender differences
in accuracy. Pennebaker speculated that women's symptom-reporting pat-
terns reflect a context that is stressful or potentially toxic, whereas men are
more oblivious to setting and focus on physiological cues.
Personality tendencies that increase symptom reporting may be more
common in women. Subjectively reported symptoms have been shown to be
systematically biased by neuroticism, which is strongly correlated with health
complaints but not actual health status (P. T. Costa & McCrae, 1987). The
personality trait of neuroticism is associated with a tendency to experience
emotional distress, including anxiety, anger, sadness, and other emotions with
negative valence (P. T. Costa & McCrae, 1992). In a healthy student popu-
lation, Neitzert, Davis, and Kennedy (1997) found that depression and neu-
roticism levels were significantly associated with higher symptom reporting
and that symptom reporting was higher in women.
P. T. Costa, Terracciano, and McCrae (2001) analyzed Revised NEO
Personality Inventory (P. T. Costa & McCrae, 1992) data from 26 cultures
(N = 23,031) and found that adult women reported themselves to be higher
in neuroticism. However, in a large meta-analysis, Else-Quest et al. (2006)
studied children up to age 13 years and found few gender differences in nega-
tive affectivity, aside from slightly higher levels of fearfulness in girls. It is
possible that small childhood differences in negative emotions are later mag-
nified by gender stereotypes. Neuroticism, anxiety, and negative affect ap-
pear to be associated with a cognitive style of heightened vigilance toward
body sensations (Pennebaker, 1994). It appears that stereotypes and gender

PSYCHOSOCIAL AND COGNITIVE FACTORS 35

Exploring the Variety of Random
Documents with Different Content
Martins joined us there a few minutes afterwards . . For eight or ten
minutes I had keen pain in my feet, caused by the change from
intense cold to warmth. I was also rather drowsy shortly after we
arrived and when the pain in my feet had stopped. I lay down on the
snow where I remained five minutes, but without being able to
sleep. Then I got up, the desire for sleep disappeared, and during
the whole time we spent on the summit I felt absolutely no painful
sensation, except a little cold the last hour. I had no appetite,
although the idea of eating caused me no disgust. M. Bravais was
also very well; only from time to time he felt the slight nausea which
M. Martins and I had observed in ourselves the day before on the
Grand-Plateau. He had an appetite and ate some biscuits and a few
prunes. Shortly after our arrival at the summit, he and I each drank
about a third of a glass of brandy. This liquor seemed to us delicious
and very mild, to our great surprise; it did us much good, and gave
us strength without causing the excitation
 Mountain Journeys 105 usually produced by alcohol. We
also drank a little wine, during the first two hours of our stay on the
summit. A moment after he reached the crest, M. Martins was
attacked by nausea, and vomited some seeds of raisins which he
had eaten an hour before. Vomiting relieved him. He compared his
illness to seasickness. When he lay down, he had no trouble, but
moving about and standing brought back the nausea. An hour
afterwards, he was better; after two hours, the sickness was
completely gone. He drank a little wine, but did not wish to eat. The
six men we had with us ate hardly anything, but they drank about
two bottles of wine and half a bottle of brandy. All were in perfect
health; only two were evidently fatigued, although they would not
admit it ... . We could walk without any difficulty on an almost
horizontal plane; but as soon as we had to climb, we were affected
by panting and general lassitude .... There was a white coating on
the tongues of all of us, but less in the guides than in us, and their
appetites were not, like ou^s, completely or almost completely
wanting. (P. 44-54.) After a few hours of observations, they
descended to the GrandPlateau; M. Martins was attacked by panting,
palpitations, and throbbing in the carotids, so that he had to sit
down. During the night, M. Lepileur felt violent sciatic neuralgia on
the left side. His appetite did not return until the next day when he
reached the altitude of 3000 meters while returning to Chamounix;
during the whole day, he had eaten only a small piece of bread
dipped in a little wine. He sent fresh provisions to Martins and
Bravais, who had remained on the Grand-Plateau; they received
them with great pleasure and made a good meal; however, what five
of them ate would hardly have equalled the ration of one man in the
valley. The urine of all of them was scanty and dark. The work of M.
Lepileur is finished by a series of tables indicating the pulse rate of
himself, Martins, and three guides from Servoz or Chamounix to the
summit of Mont Blanc. He summarizes it as follows: The increase of
the pulse rate is a constant result, when one is ascending, beginning
with a certain elevation, .... which may vary with the individual ....
My pulse was less frequent at Chamounix (60) than at Paris (67.25) ;
. . . . the contrary was true of M. Martins .... The ratio of frequency
between Chamounix and the summit is: for M. Martins 0.82; for me
0.68; for Muguier 0.67; for Couttet 0.60; for Simond 0.61. (P. 77-
80.) M. Martins143 much later narrated the same journey; his
recollections agree with those of M. Lepileur: On the Grand-Plateau
the guides began to clear snow off the tent.
 106 Historical This work was painful; each of them had
hardly removed a few shovelfuls when he stopped to breathe; a
hidden distress was revealed on every face; appetites were gone.
Auguste Simon, the tallest, the strongest, the most daring of the
guides, collapsed upon the snow, and almost fainted while Dr.
Lepileur was feeling his pulse; it was the effect of the rarefaction of
the air added to fatigue and insomnia, from which all of us suffered
more or less. We were then about 4000 meters above sea level, and
there are few men who are not inconvenienced at 3000 meters. I am
not surprised that in this ascent we felt the effects of the rarefaction
of the air, which we had hardly noticed in the two previous ascents.
Never had we mounted so quickly from Chamounix to the Grand-
Plateau; starting from 1040 meters above sea level, after ten and a
half hours of walking we were at an elevation of 3930 meters; that is
a difference in level of 2890 meters, traversed in less than a half
day. All discomfort disappeared when we ceased moving. (P. 25 of
the separate printing.) The next day, they finished the ascent: The
rarefaction of the air ... . compelled us to walk slowly; every twenty
steps we stopped breathless .... We were reaching the goal, but we
were walking slowly, our heads lowered, our chests heaving, like a
procession of invalids. The effect of the rarefaction of the air was felt
painfully: the column paused constantly. Bravais wishes to find out
how long he could continue climbing as quickly as possible; he
stopped at the thirtysecond step without being able to take one
more. At last at a quarter of two we reached the long desired
summit. (P. 27.) The account of the ascent of July 19, 1859, made
by MM. Chomel144 and Crozet, has also given us interesting
observations; they followed a route different from the usual one,
from the beaten path, we may say, so frequent have journeys to
Mont Blanc become: There comes at last the cap of Mont Blanc,
which, in spite of its slight elevation above the Mer de Glace,
nevertheless requires two more tedious hours of ascent. During this
last stretch, the lack of air makes every movement of the body
painful, and one must make superhuman efforts to resist
palpitations, sleep, and fainting .... Only a few feet now separate us
from this long-desired summit. Our self-respect spurs us on, and
rising from the snow on which we were stretched, we cover the rest
of the way at a run .... And here we are on the summit of the giant
of the Alps. The first impression .... was, alas! a dizziness and
contractions of the stomach which made us reel. The celebrated
English physicist Tyndall145 is one of the most ardent mountaineers
in the Alps. Every year sees him planting his alpenstock on some
new summit. And it is not only with a scientific purpose that he runs
thus the greatest dangers; it is not
 Mountain Journeys 107 only the great spectacles of nature
which attract him and thrill him; he too seems gripped by this
passion for climbing for the sake of climbing, which, though it had its
origin in England, is making progress today in our own country. But
his evidence has all the more value for these different reasons.
August 12, 1857, Tyndall made his first ascent of Mont Blanc, in the
company of MM. Hirst and Huxley. The latter had to stop at the
Grands-Mulets. When he reached the Derniers Rochers, Tyndall felt
exhausted. The guide Simond cried at every halt: "Oh, how my
knees hurt!" I lay down upon a bed composed of granite and snow,
and went to sleep immediately. But my companion soon awakened
me: "You frightened me," he said, "I have been listening for several
minutes, and I have not heard you breathe once." We got up then, it
was half past two .... To the feeling of fatigue we had felt till then
was added a new phenomenon, palpitations. We were constantly
subject to them, and sometimes they became so severe as to cause
some apprehension. I counted the number of steps that I could take
without stopping and found it to be fifteen or twenty. At each halt
my heart beat hard enough to be heard as I was leaning on my
alpenstock, and its subsiding was the signal for a new advance. My
breath was short, but easy and unhampered. I tried to find out
whether the articulation of the thigh was relaxed because of the
decreased pressure, but I could not be sure .... After we had passed
the Derniers Rochers, we struggled on with the stoical indifference
of men who are carrying out a duty without bothering about the
results. At last a ray of hope began to brighten our spirits; the
summit was visible, Simond showed more energy .... at half past
three I clasped hands over the summit. (P. 80.) The account of the
second ascent, made September 12, 1858, merely alludes briefly to
the fatigues of the mountains, (p. 189.) In 1859, an ascent still more
important and very profitable for science. Tyndall, Frankland, and
nine guides passed a night on the summit of Mont Blanc; they
stayed there about twenty hours:14"' We did not suffer from the
cold, although we had no fire and the snow was at a temperature of
— 15°C. But we were all ill. I was sick when I left Chamounix .... I
had frequently conquered my discomfort on previous occasions, and
I hoped for the same thing this time. But I was absolutely
disappointed; my illness was more deeply rooted than usual, and it
grew worse during the whole ascent. But the next morning I was
stronger, whereas the opposite was true for several of my
companions. (P. 54.) The same year, a German, Dr. Pitschner,147
made a remarkable ascent of this same mountain; he was very
seriously affected:
 108 Historical At six o'clock in the morning, we were in the
Corridor (3,990 meters) ; the thermometer marked — 8°C. We had
hardly been there five minutes when a strong desire to sleep seized
us, and conquered me completely. My respiration was very painful;
my eyes blinked, I had buzzings in my ears, headache, nausea; soon
I vomited repeatedly; Balmat was as much affected as I, and his
desire to sleep was so great that he lay down on the snow, and I
immediately let myself fall beside him. "I cannot go any further
without sleeping a half-hour", I said to Balmat .... I fell into a
lethargic sleep, interrupted by smothering spells, which finally
seemed dangerous to Balmat; and so he began to stir me and shake
me, without being able to awaken me. Fifteen minutes passed. His
shouts awoke me, and he said to me: "You cannot stay here any
longer, you must go on". Perspiration covered my face; I rubbed my
face with snow, and after a score of deep breaths, I felt better ....
From my sensations on the glacier, it is evident that the effect of
mountain air was evidenced in me very definitely; it produces
dangerous congestions .... On our return, at three o'clock in the
afternoon, the same symptoms appeared in the same place, but with
much less intensity: headache, nausea, vomiting. The expedition of
Dr. Piachaud,14S July 26, 1864, gave results just as interesting. The
author gave heed to the physiological phenomena experienced by
his companions and himself, and "attributed to the rarity of the air":
The chief symptom (he says) is the oppression, which hardly exists
when one is resting, but which appears as soon as one starts
walking, then stops again when one halts. From it there results the
necessity of increasing the number of inspirations, and thence such
a fatigue that one is forced to halt every twenty or twenty-five steps.
This fatigue, moreover, is not like that one feels as the result of a
long walk; it is not the legs which are chiefly affected; it takes
possession of the whole system; there is a sort of general
depression both mental and physical. I should add that this peculiar
condition is observed only during the ascent, for once I had reached
the summit and during the descent, I felt nothing of the sort.
Another noteworthy effect of the rarity of the air is sleepiness, which
I could hardly resist; I felt that if I had stretched out on the snow, or
if I had been alone, I should have gone to sleep immediately. I do
not think that this drowsiness can be attributed to the cold, for on
the summit, where the cold was very keen, I was wide awake. I also
experienced very slight vertigo, but I mention it only to omit
nothing. As for nausea, vomiting, fainting, hemorrhages, none of us
was affected by any of them; our guides, of whom I asked
information on these different points, told me that they had never
observed hemorrhages. As to oppression, which is the symptom
most frequently observed, I should say that it is far from being
absolute, for of the six of us, I am the only one who felt it very
definitely; the guides
 104 ___. 104 108 ___. 104 108 ___. 104 96 ___. 96 92 80
Mountain Journeys 109 did not complain of it and M. Loppe could
run when he got near the summit. (P. 86.) Examination of the pulse
rate gave the following results: Chamounix Grands-Mulets Mont
Blanc 1000 meters 3000 meters 4800 meters Carrier, guide 116
Couttet, guide 96 Tournier, guide 96 Payot, guide 92 Loppe, traveller
88 I now come to the two ascents of Mont Blanc which were
noteworthy from the standpoint that interests us because for the
first time the whole combination of physiological phenomena was
studied with the precision instruments used in laboratories.
Disturbances of circulation and respiration were thus determined in
the conditions which the present exactness of physiological research
demands. Besides, these observations serve as a basis for an
entirely new theory of mountain sickness, which will be discussed in
its proper place. M. Lortet149 begins with a rapid historical survey of
the symptoms felt by the most celebrated travellers. Then, before
beginning the account of his journey, he lets escape the precious
confession of an incredulity of which I have often heard Alpine
travellers boast, even those who had made the most difficult
ascents: However, in spite of so many data and proofs reported by
these distinguished men worthy of credence, I had been a little
incredulous and I could not help believing that imagination played a
great part in the production of these phenomena. On the main range
of Monte Rosa I had often ascended heights of more than 4300
meters without any difficulty and without the least discomfort, and I
could not believe that 500 meters more were enough to affect an
organism which had stood the test very well up to this altitude. Now
I am forced to admit it, I have been convinced de visu, and even a
little at my expense, of the very real existence of symptoms which,
above this altitude, attack anyone who breathes and particularly
anyone who moves in this rarified air. (P. 11.) He then comes to the
account of his first ascent with Dr. Marcet, August 16, 1869. I copy
the important points of his description, which is remarkable for its
exactness and moderation: Up to the Grands-Mulets (3050 meters),
where we arrived at 3 o'clock to pass the night, we were well; no
one felt the least discomfort; we all had excellent appetites; but
already our instruments announced serious disturbance of
circulation, respiration, and especially calorification, (heat
production)
 110 Historical The night at the Grands-Mulets was horrible
.... At half-past two we set out. At daybreak they reached the Grand-
Plateau (3932 meters) : We stopped a moment to breathe .... The
guides took a little nourishment; but it was completely impossible for
me to swallow a single mouthful, although I still felt quite well. We
climbed very slowly; we all felt an inclination to sleep which was very
difficult to struggle against and an intense occipital headache, thirst
and dryness of the throat, only a few palpitations, but a wretched
pulse which varied between 160 to 172 per minute. When we
reached the ridge, we were all tired, and it seemed to me that it
would be completely impossible for me to go further. None of us
vomited, but almost all of us were nauseated. Like those who are
attacked by seasickness, I was completely indifferent about myself
and the others, and I wanted only one thing, to remain motionless.
The Englishmen who were following us seemed even more affected
than we were; one of them was obliged to stop and soon retraced
his steps. At last they reached the summit of Mont Blanc: I no longer
felt any kind of illness, but the breathlessness was extreme as soon
as I wished to take a few steps rapidly. The least movement caused
me disagreeable palpitations. One of my companions, who had felt
no ill effect until then, was attacked suddenly, as soon as he had
reached the summit, by dizziness and almost constant vomiting
which did not cease until he reached the Grand-Plateau on the way
down. His stomach was empty, so that he vomited only glairy and
bilious matter with very painful efforts. Nothing succeeded in
stopping this stomach trouble; only one thing seemed to relieve his
condition at all, that was small fragments of pure ice which he
managed to swallow from time to time. His pulse was very uneven,
very wretched, and the thermometer placed under his tongue hardly
went above +32°! The sun was warm, the atmosphere fairly calm,
so it was with surprise that I observed that the temperature of the
air was — 9°. We remained at the summit nearly two hours to make
the experiments of which I shall speak later. While I was resting, I
felt quite well, although it was impossible for me to take the least
nourishment. (P. 16.) The second ascent went much better. The
night at the GrandsMulets was good; magnificent weather made the
walking easy: We felt almost no discomfort except a leaden
sleepiness while we were climbing the slope which leads to the
Dome. I have never felt anything like it, and I am sure that I slept
while I was walking. But when I reached the ridge, the cold air and
rubbing my forehead with snow removed this congestion. I felt much
better than on the first ascent. I even had an appetite and could eat
some morsels with pleasure. However, breathlessness
 Mountain Journeys 111 at the slightest movement was still
intense. One of our companions experienced great nausea, complete
lack of appetite, but did not vomit. (P. 18.) After this general
description, M. Lortet passes to the analysis of the disturbances in
the various functions. And at the beginning he is careful to say:
Hardly noticeable while going from Lyons to Chamounix, that is,
passing from a height of 200 meters to an altitude of 1000 meters,
their disturbance is, on the contrary, very appreciable from
Chamounix to the Grands-Mulets (from 1050 to 3050 meters), still
plainer from the Grands-Mulets (3050 meters) to the Grand-Plateau
(3932 meters) ; finally this change becomes very great from the
GrandPlateau to the Bosses-du-Dromadaire (4556 meters), and at
the summit of the Calotte of Mont Blanc (4810 meters). We shall
therefore review the variations undergone by the respiration, the
circulation, and the inner temperature of the body, taken under the
tongue at different altitudes, either while walking, or after a suitable
period of rest. (P. 20.) Respiration: From Chamounix to the Grand-
Plateau (from 1050 to 3952 meters) disturbances of respiration are
slight in those who know how to walk in the mountains, who keep
their heads lowered to lessen the laryngial orifice, who breathe with
their mouths closed, being careful to suck an inert object, such as a
hazelnut or a little piece of quartz, which considerably increases
salivation and prevents the drying out of the air passages. From
Chamounix to the GrandPlateau, the number of respiratory
movements is hardly changed; while at rest, we find twenty-four per
minute, as in Lyons and in Chamounix; but from the Grand-Plateau
to the Bosses-du-Dromadaire and to the summit, we find thirty-six
movements per minute. The breathing is very short and very
difficult, even when one remains quiet; it seems as if the muscles
are stiffened and the ribs are held in a vise. At the summit, the
slightest movement brings on panting; but after two hours of rest
these discomforts disappear little by little. Respiration drops to
twenty-five per minute, but it still remains painful. (P. 20.) M. Lortet
studied the changes in the amplitude of his respiration with the
anapnograph of Bergeon and Kastus; the two tracings below give a
very complete idea of them; in both, the area GFED represents the
inspiration, the area DCBA, the expiration. Comparing the tracing of
Figure 1, taken at Lyons, with the following, taken at the summit of
Mont Blanc, after a rest of an hour and a half, we see that the
quantity of air inspired and expired at the summit of Mont Blanc is
much less than at Lyons. Circulation: During the ascent, although
progress is excessively slow, the circulation is accelerated
extraordinarily. At Lyons', when I am resting and fasting, my average
pulse rate is sixty-four per
 112 Historical minute. While I was climbing from
Chamounix to Mont Blanc, it increased progressively, following the
altitudes, to 80, 108, 116, 128, 136; and finally, while I was climbing
the last ridge which leads from Fig. 1— Lortet. Respiratory tracing
taken at Lyons (200 m.) Fig. 2 — Lortet. Respiratory tracing taken at
the top of Mont Blanc (4810 m.) after an hour's rest. the Bosses-du-
Dromadaire to the summit, to 160 and sometimes more. These
ridges, it is true, are very steep, they have a grade of forty-five to
fifty degrees; but slowness of the walking is very great. One
generally takes thirty-two steps per minute and often much less
when steps have to be cut constantly. The pulse is feverish, hasty,
and weak. It is plain that the artery is almost empty. The slightest
pressure stops the current in the blood-vessel. The blood must pass
very rapidly in the lungs, and this rapidity increases still more the
insufficient oxygenation which has already resulted from the
rarefaction of the air. It does not have time to receive the oxygen
adequately, and neither does it have time to give off its carbonic acid
entirely. Above
 Mountain Journeys 113 the elevation of 4500 meters, the
veins of the hands, the forearms, and the temples are distended.
The face is pale with slight cyanosis, and everyone, even the guides
acclimated to these lofty regions feel a heaviness in the head and a
drowsiness which are often very painful, due probably to a venous
stasis in the brain or to a failure of oxygenation of the blood. Even
after two hours of complete rest at the summit and fasting, the
pulse always remains between 90 and 108 beats per minute. (P. 23.)
We reproduce as very interesting examples the following
sphygmographic tracings (Figs. 3, 4, 5) which, made by M.
Chauveau of Lyons at the time of his ascent in 1866, give all
necesFig. 3 — Cupelain; at Chamounix (1000 m.) Fig. 4— Cupelain;
at the Grands Mulets (3000 m.) at midnight, one halfhour before
starting. Fig. 5— Cupelain; top of Mont Blanc (4810 m.) sary proofs
of accuracy. The guide Cupelain, who was the subject, is a very
vigorous young man, who seems not to suffer from mountain
sickness at all. For M. Lortet, who does suffer from it, the changes
were still more considerable. Temperature. We now come to the
subject to which M. Lortet gave most attention, and which serves as
a basis for his theory of mountain sickness. I continue to quote
verbatim: The thermometer was placed under the tongue, the
buccal orifice being always closed hermetically, and respiration going
on only
 114 Historical through the nose .... The instrument was
always left in place for at least fifteen minutes. (P. 31.) Fasting, while
walking continues, the decrease of the temperature is, according to
M. Lortet, almost proportional to the altitude at which one is. This is
shown by the following table. Lortet: Temperature First Second
Temperature Ascent Ascent of the air 'x First Second in .fj < '3 OS '3
Ascent Ascent 3 « Chamounix 1050 36.5 36.3 37.0 35.3 + 10.1 +
12.4 64 Cascade du Dard 1500 36.4 35.7 36.3 34.3 + 11.2 +13.4 70
Chalet de la Para 1605 36.6 34.8 36.3 34.2 + 11.8 + 13.6 80 Pierre-
Pointue 2049 36.5 33.3 36.4 33.4 + 13.2 + 14.1 108 Grands-Mulets
3050 36.5 33.1 36.3 33.3 — 0.3 — 1.5 116 Grand-Plateau 3932 35.3
32.8 36.7 32.5 — 8.2 — 6.4 128 Bosse du Dromadaire 4556 36.4
32.2 36.7 32.3 —10.3 — 4.2 136 Summit of Mont Blanc 4810 36.3
32.0 36.6 31.0 — 9.1 — 3.4 172 So during the muscular efforts of
the ascent, the temperature of the body may drop four or five
degrees, when one mounts from 1050 to 4810 meters. As soon as
one stops for a few minutes, the temperature rises quickly to nearly
its normal figure .... Since my return to Lyons, I have observed that
when one ascends rapidly one of the numerous stairways that lead
to Fourvieres or the Croix Rouge, there is regularly a drop in
temperature which varies almost always from three to seven tenths
of a- degree. (P. 32.) It is to this drop in temperature of the body
that M. Lortet attributes all the symptoms of mountain sickness. In
Chapter III we shall give this theory and the objections it has
aroused. The same day when MM. Lortet and Marcet suffered so
severely during the ascent, M. Ch. Durier150 followed them,
walking, so to speak, in their footsteps. Strangely enough, neither he
nor his companions felt any symptoms: There were three of us,
three companions of very different temperament; one was a lad
fifteen years old, the youngest traveller — at least that I know of —
ever to ascend Mont Blanc. Well! None of us felt the slightest
discomfort, not even breathlessness. (P. 66.) Why this difference in
impression? M. Durier asks himself. And to this question he gives an
answer full of acuteness, of which we shall make use later.
 Mountain Journeys 115 I shall end the review of the
principal ascents of Mont Blanc with that of M. Albert Tissandier;1M
it is particularly interesting because its author, being an aeronaut,
could compare his sensations with those he felt in a balloon; he had
no uncomfortable sensations: At the height of 4400 meters,
respiration began to be somewhat painful and panting, but I
endured the effect of the rarefaction of the air without very much
trouble. My two guides looked at me at that time, and told me that
often, at that altitude, travellers have a peculiar color; sometimes
their vision grows dim and their strength fails; then they have to be
hoisted up with great difficulty or else descend, depending upon the
energy the traveller possesses. I should have been very sorry to be
obliged to descend. In a balloon I have reached altitudes almost
equal to that of Mont Blanc without being inconvenienced; but a
mountain ascent, slow and painful, is not at all like the ascent one
makes so quickly and easily in the basket of a balloon. The ascent of
Mont Blanc, so much feared before the daring attempt of Jacques
Balmat, and which the sufferings of De Saussure and then the
accident of Dr. Hamel had invested with a terrifying renown, has in
our time become frequent, almost common. In 1873, sixty travellers
ascended to the summit of the giant of the Alps, among them seven
women and a lad of fourteen, the youngest who has ever made the
ascent, named Horace de Saussure. Since the time of the illustrious
ancestor of this brave lad, I have counted on the list still incomplete
given by M. Besangon,1"'2 which goes to the end of 1873, 828
ascents, 27 of which were made by women. The last, made by an
Englishwoman, Mrs. Straton, shows remarkable courage; it took
place January 31, 1876; on the summit the lady found a
temperature of —24 degrees. But the large majority of these
expeditions offer no scientific interest; they are mere tourist
excursions, often managed very imprudently. Mont Blanc, of which
the professional "mountaineers" speak with a certain disdain, seems
to avenge itself; there have been more serious accidents upon it
than in all the rest of the Alps. One of these disasters, the most
terrible of all, perhaps has some relation to our subject. September
6, 1870, nine guides and three travellers reached the summit of
Mont Blanc; they could not get down, and died the next day in the
snow. In the pocket of one of them, M. Beau,1"3 was found a paper
giving an account of their sufferings: We passed the night in a
cavern dug in the snow, a very uncomfortable shelter; I was sick all
night.
 116 Historical Most of those who have made recent ascents
of Mont Blanc, the accounts of which have been preserved for us by
the Alpine clubs, say nothing of mountain sickness. They go on at
length about the preparations for the departure, the petty incidents
of the journey, the joys of the return, but maintain complete silence
about the physiological phenomena. And what I say of Mont Blanc is
true of all the other ascents, even of mountains rivaling it in height. I
have gone over, page by page, the journals of the English, Swiss,
Italian, Austrian, and French Alpine clubs; I have patiently read
hundreds of monotonous accounts, and have found very few data
relating to our study; I shall mention them chronologically. August
13, 1857, M. Hardy ir'4 made the ascent of the Finsteraarhorn (4275
meters) : Wellig (inn-keeper of Eggischhorn), considering himself
insulted by our jokes, went on ahead to reach the summit first. But
hardly had he taken a hundred steps, when he fell as if some one
had shot him. Ellis, who was walking behind him, thought that he
was resting, and walked quietly up to him; but when I came, I
perceived that it was more serious. His eyes were turned up, his
mouth open, and he looked strangely like a fish. I did not know what
to do; but Cruz adopted a queer mode of treatment .... He raised
him to a seated posture and shook him so vigorously backward and
forward, that after a few vibrations he revived from his faint, got up,
and went to join Fortunatus. (P. 299.) Perhaps we may hesitate to
attribute this sudden syncope to mountain sickness; but in the
narrative of Tuckett,15"' the doubt is not possible. The matter in
question is an ascent on Grivola (3960 meters), made in June 1859;
an avalanche threatened to carry away the travellers: Chabot, one of
the guides, complained of painful sensations in the chest and
stomach, loss of appetite, vertigo, nausea, headache, resulting partly
from fear and fatigue, and partly also, perhaps, due to the rarity of
the air, for we had reached the height of 12,028 feet (3665 meters).
(P. 297.) In my opinion, in spite of the complication of a somewhat
exaggerated consumption of alcoholic beverages, the influence of
rarified air is incontestable again in the following observation158: A
young Englishman about twenty-four years old, a regular picture of
health and strength, passed the Weissthor by Macugnagna. He was
not much accustomed to difficult ascents .... and to give himself
strength drank brandy and water frequently. The result was soon
seen. The guides had to pull him along with ropes, in a state of
 Mountain Journeys 117 complete exhaustion .... In fact, as
he told me, he has no notion of the way in which he overcame the
difficulties and reached the summit; he was in an inert stupor the
whole time. (P. 349.) M. Kennedy,157 one of the most daring and
one of the first men to make ascents in the Alps, was himself
attacked in one of his expeditions, not the first, far from it, nor the
most difficult, nor the highest; he was climbing the Dent-Blanche
(4365 meters) and was still far. from the summit: An extraordinary
weight seemed to be loaded on me, hampering my movements. My
legs, although I did not feel fatigued, refused to act with their usual
vigor, and I was left far behind; but the pure and rarified air which
blew over us and the sight of the peak of the DentBlanche began to
revive me. (P. 36.) In certain accounts, it is only incidentally, as if
buried in a sentence, that we see the symptoms of mountain
sickness appearing: Guides and travellers were exhausted, stopping
often for breath 15S .... (P. 107.) In other cases they are more
clearly indicated, even described. The snow was hard, it was
necessary to cut steps, and more159 than once the travellers had to
stop to get their breath. (P. 166.) In 1864, Craufurd Grove160
ascended to Studer-joch (3260 meters) ; too great speed in walking
made travellers and guides ill: Perru, who was afraid of avalanches,
made us walk at a pace unusual in the Alps, which quickly produced
signs of distress in the whole group; .... but the robust son of
Zermatt gave no heed, and slackened his pace only when the
outraged laws of respiration claimed their rights and compelled him
to stop completely to get his breath . . . We reached the summit; but
our joy was greatly lessened by the fact that we were almost all ill.
Some of us who had relaxed beside Italian lakes from the hard work
of the mountaineer had eaten figs and grapes in excess. The result
of this diet, while we were walking on the ice, was too painful to be
described. The guides were in a hardly less pitiful condition; they
had drunk Grimsel brandy the night before. (P. 368.) The account of
the ascent of Monte Rosa by Visconti,"'1 in August, 1864, is still
clearer and more interesting: The rarefaction of the air
inconvenienced us greatly, either because of the difficulty in
breathing or because of the decrease of atmosphere pressure on the
blood-vessels. For these reasons and because of the steepness of
the grades, our legs and lungs tired quickly; but a few moments of
rest restored their strength rapidly . . .
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