Personality Traits and Dysfunctional Attitudes among Patients with Somatic Symptom Disorder in Pakistan

Somatic symptom disorder was previously known as somatization disorder, is the combination of medically unexplained bodily symptoms with psychological anxieties and health-seeking behavior. It occurs in 10% to 15% people in OPD. The objective was to investigate the relationship between personality traits and dysfunctional attitudes among somatic symptom disorder patients (SSD) and differences in personality traits of somatic symptom disorder patients and normal individuals. A total sample (N= 140) of seventy diagnosed patients (n = 70) of somatic symptom disorder and seventy (n= 70) normal individual were taken. Dysfunctional attitudes were measured by short form of Dysfunctional Attitude scale (DAS) developed by Beck, Brown, Steer and Weissman, (1991), whereas personality traits were measured by NEO-personality inventory developed by Costa and McCrae (1985).Neuroticism personality trait was positively correlated with dysfunctional attitudes whereas Conscientiousness, openness, extroversion and agreeableness were negatively correlated with dysfunctional attitudes among somatic symptom disorder. There were significant differences in personality traits of patients with somatic symptom disorder and normal individuals. Personality traits are associated with dysfunctional attitudes among patients with somatic symptom disorder and personality traits of somatic symptom disorder patients are different from normal individuals.


2014
). According to DSM-5, somatic disorder patients have recurrent somatic illness for at least six months (American Psychiatric Association, 2013) without any medical basis. In the last 20 years, epidemiological and clinical studies published showed that complaints of somatic symptom disorder lack enough medical basis, rather have psychological causes (Wallenet al., 1987).
People in non-western cultures communicate their feelings through body language, as they do not have understanding of emotional sufferings (Minhas & Nizami, 2006).Such preventions of communication are frequently strengthened by the religious connotations, gender roles, sociocultural influences and beliefs (Schwartz, Calhoun & Eschbich, 2001). Three epidemiological survey indicated that mental disorders are common in Pakistan, and people usually present their complaints in physical symptoms. Bradford Somatic Inventory (BSI), was used in these three surveys, developed from the reports of symptoms of psychosomatic patients. This inventory was in local language and used all native cultural phrases for stress and pain to investigate the somatic symptoms. They found that 66% of women and 25% men have depression and anxiety; however main presentation of their symptoms were somatic.
Personality plays an important role in understanding the mental health. Since the start of the medicine the significance of personality traits to psychopathology has been accepted (Widiger & Smith, 2008). Personality can be defined as "An individual's characteristic style of behaving, thinking, and feeling" (Schacter, Gilbert, & Wegner, 2009). It defines individuals own style, way of interaction with the environment. Earlier studies supported the Five Factor Model (FFM), as an important concept in psychology (Aboaja, Duggan, & Park, 2011), it is of great significance to the mental health field by incorporating and structuring different ideas and measures (Mc Crea & Costa, 2008). Big five taxonomy have some presumption concerning human nature and distinctive characteristics and helps us in understanding and discriminating about normal functioning.
The big five factor model (FFM), Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness are important in promoting or damaging mental health as associated with distinctive adaptations. Neuroticism is associated with illogical beliefs, pessimistic approaches and hopelessness. Extraversion is associated with social relations, participating in group activities, various friendships. Openness is associated with numerous hobbies, travelling, varied vocational interests and adventures. Agreeableness is associated with harmless language, trust in cooperation and sympathetic attitude. Conscientiousness is associated with practical expertise, leadership abilities and long term ideas.
Personality traits effects individuals attitudes and may contribute to somatic symptom disorder. There is certainly no misunderstanding that personality is powerfully associated with various major psychological disorders (Hettema, Neale, Myers, Prescott, & Kendler, 2006). It has been found that the somatic symptom disorder (SSD) is associated with a high rate of personality disorders as compared to other psychological illness (Axis 1 disorder) (Buss & Murphy, 1995). Cross sectional studies has also found association between personality and psychopathology and specifically with personality disorders (Wright, Pincus, & Lenzenweger, 2011). Individual's characteristics and personality traits influence their psychological wellbeing (Josefsson et al., 2011). Personality traits might also influence the use, course and efficacy of a variety of management of mental disorders (Harkness & Lilienfeld, 1997).
Attitude has component of thought, behavior and emotions which can be observed in ones values, personality and beliefs. Dysfunctional attitudes are maladaptive cognitive biases and negative beliefs related to self, world, and future. They are stable and inflexible, based on irrational thoughts, interrupt responses, and results from how people think, evaluate and infer their life incidents (Beck, 1967). Different studies showed that personality pathology is related with attitudes and behavior, person with personality disorders have more cognitive distortions (Farahbaugh et al., 2007). Dysfunctional attitudes has following characteristics a) dysfunctional attitudes are not practical, b) they are fixed, extreme and common, c) Inhibit the person from presenting his real abilities, d) cause severe emotional instabilities e) dysfunctional attitudes are not influenced by daily experiences (Savaşır, Boyacıoğlu & Kabakçı, 1996).
Dysfunctional attitudes are associated with depression and anxiety, whereas depression has co-morbidity with different psychiatric disorders, in nearly 80% of the populations of Pakistan (Alvi & Minhas, 2009).In research history, dysfunctional attitudes have been related with depression in comparison to other mental disorders, although depression symptoms are common in somatic symptom disorder patients (Pehlivanturk & Unal, 2000). Understanding of psychological factors apart from stressful and traumatic experiences like emotional processing and defense mechanisms are helpful in deciding causes of somatic symptom disorder and developing effective psychotherapeutic interventions for them (Brown, 2004).
As somatic symptom disorder is common psychological disorders in non-psychiatric set up and causes worldwide medical, psychological, social and economic problems, yet relationship between personality traits and dysfunctional attitudes among somatic symptom disorder is not completely understood. The present study aimed at exploring (1) whether neuroticism personality trait is positively associated with dysfunctional attitude among somatic symptom disorder, (2) whereas other personality traits like extroversion, conscientiousness, agreeableness and openness negatively associated with dysfunctional attitudes in somatic symptom disorder patients. (3) This study has also attempted to find whether the personality traits of somatic symptom disorder patients are different from that of normal Individual.

Sample
In current study purposive convenient sampling is used. Seventy patients (n=70) with somatic symptom disorder were selected from department of psychiatry Benazir Bhutto hospital Rawalpindi and Pakistan Institute of medical sciences, Islamabad in comparison to 70 normal individuals. The age range of subjects was from 18 to 45 years. Subject was selected with respect to their demographic variables such as age gender, education, monthly income, family structure.
Inclusion criteria of present study were informed consent to participate, age 18-45 years. Exclusion criteria were known psychiatric disorder. Total 76 somatic disorder patients fulfilled the criteria of study, but 6 participants refused to participate because of practical reasons. Thus 92% subject voluntarily participated in the study. Due to limited resources sample of the study could not be improved. The demographic characteristics of participants is presented in Table 2.

Neuroticism Extroversion Openness Five-Factor Inventory (NEO-FFI):
To measure the personality traits of participants, NEO-FFI (Five-Factor Inventory) developed by Costa and McCrae (1985) was applied. Each of the five factors was assessed using 12 items from a total of 60 items of big five. It is used to measure the five personality traits as described by Five Factor Model, Openness, Conscientiousness, Extraversion, Agreeableness, and Neuroticism. A five-point Likert scale was used ranging from 1 (strongly disagree) to 5 (strongly agree). 2. Dysfunctional Attitude Scale (DAS): Dysfunctional attitudes were measured by short form of dysfunctional Attitudes scale developed by Beck, Brown, Steer & Weissman, (1991). It has 40 items. Each item draws information related to person's dysfunctional attitudes about self, world and people. A 7-point Likert scale was used, ranging from 1 (totally agree) to 7 (totally disagree).

Procedure
First of all, after the ethical approval from ethical committee of International Islamic University, Islamabad and head of department of the psychiatric hospital of Rawalpindi and Islamabad, patients were approached. Informed consent was taken from them that they were willingly participating in research and could leave study at any time without informing. Seventy normal individuals who have never been diagnosed with any psychological disorder were selected. The Purpose of the research was explained to them. They were presented with a questionnaire and asked to answer the statement which best suits to them. Participants were assured that collected data would be kept confidential and would be only used for research purpose.    Table 2 shows demographic characteristics of patients with somatic symptoms disorders.  Table 3 shows that neuroticism is positively correlated with dysfunctional attitudes whereas extroversion, conscientiousness, agreeableness and openness are negatively correlated with dysfunctional attitudes in somatic symptom disorder patients.  Table 4 shows the significant mean difference between the personality traits of somatic symptoms disorder patients and normal individuals. There are significant differences among personality traits of patients with somatic symptoms disorders and normal individuals. The results are statistically significant at 0.05, level of significance.

DISCUSSION
The purpose of current study was to investigate the relationship of personality traits with dysfunctional attitudes and to compare the personality traits of patients with the somatic disorder with normal individuals. The first hypothesis of the study states that neuroticism is positively correlated with dysfunctional attitudes among somatic symptom disorder patients. This hypothesis has been accepted in the current study. People with neuroticism personality traits are emotional, anxious and are prone to stress (Cherry, 2017).They perceive situation as threatening and complete catastrophe and endure dreadful state of mind. Neuroticism among big five factor is associated with psychopathology. For instance, half of the personality disorders are correlated with neuroticism (e.g., Aboaja, Duggan, & Park, 2011).
An Individual with neuroticism personality traits experience more dysfunctional attitudes as compare to extroversion. However, Presence of dysfunctional attitudes in somatic symptom disorder cannot be considered as a cause of the disorder but it can be assumed as an important element of cognitive perspective of the patients of somatic symptom disorder. Therefore, it has been acknowledged that dysfunctional attitudes are common in different psychological disorders. Krueger, McGue, and Iacono (2001) found that common psychological disorders are linked with personality characteristics. Gomez et al., (2009) has also found that there is strong negative association between neuroticism and subjective well-being (SWB), and strong positive association between extraversion and subjective well-being. Quevedo and Abella (2011) studied other personality characteristics such as self-esteem, social support and optimism, not included in Big Five Model to see whether they predict SWB strongly than Big Five personality dimensions. Their findings showed that neuroticism was negatively linked with positive affects and extraversion has inverse relationship with negative affects. Extraversion and neuroticism were correlated with happiness; Person with high extraversion and low neuroticism had higher level of happiness.
The second hypothesis of the study stating that Conscientiousness, Extroversion, Agreeableness and Openness are negatively correlated with dysfunctional attitudes in somatic symptom disorder patients. People who have conscientiousness' personality traits participate in healthy activities and avoid harmful and unhealthy life styles and activities (Boggand & Robert, 2004).Individuals with openness personality traits focus their insight and imagination more as compare to closed people, whereas people with agreeableness traits are kind and helping instead of being destructive and suspicious toward others. It is considered as productive personality trait and is less associated with dysfunctional behavior. Extraversion personality traits includes enthusiasm, dynamism, social and positive strengths (Cherry, 2017). Fleeson, Malanos, & Achille, (2002) has found that extroversion personality traits is negatively associated with dysfunctional attitudes whereas it has positive correlation with happiness.
In a comprehensive meta-analysis, Steel, Schmidt, and Shultz (2008) evaluated the relationship between individual personality traits and subjective well-being (SWB). Their results showed a robust association between personality traits, neuroticism, extraversion, agreeableness, conscientiousness and all elements of SWB, whereas openness to experience showed close relationship with positive affects, quality of life and happiness facets of SWB. Halamandaris, and Power (1997) investigated that students who had extrovert personality traits had less dysfunctional attitudes as compare to students with neuroticism traits. Conscientiousness and agreeableness personality traits effects the interaction of individual with health care professionals which causes failure of therapeutic reassurances and reduction in emotional distress which is common among somatic symptom disorder patients (Kirmayer, Robbins & Paris, 1994).
Third hypothesis of the study states that personality traits of patients with somatic symptom disorder are different from personality traits of normal individuals. Results confirmed the hypothesis. There is no doubt that personality pathology is associated with different clinical psychological disorders. Somatic symptom disorder patients have more Neuroticism and negativistic personality characteristics in comparison to agreeableness personality traits (Russal et al, 2001). Somatic symptom disorder is associated with psychological factors rather than physical causes (Kallivayalil, & Punnoose, 2010). In current study most of the patients were female, married and uneducated and they reported different stressors i.e. financial crises, and relationship problems associated with their illness. Because of social roles, life cycle and responsibilities, women in Pakistan experience more psychological disorders as compare to male (Niaz, 2004). In non-western culture, people frequently communicate their problems into somatic complaints instead of psychological symptoms.
Current studies also have some limitations. Sample size was very small, only 70 somatic symptom disorder patients and 70 normal individuals were recruited. Therefore, this sample was not true representative. Age of the subjects of current study were range 18 to 45, whereas increasing the age range may reveal to some other facts. Result of the current study could not generalize to the whole population as data was only taken from few cities of Pakistan Rawalpindi and Islamabad.
Current research could be helpful for mental health professionals, social workers, psychologists and psychiatrists. After identifying the dysfunctional attitudes, they may develop appropriate management plan to treat somatic symptom disorder and associated anxiety, and depression by emphasizing cognitive restructuring. Future researches may investigate other psychosomatic determinant of somatic symptom disorders.
It can be concluded from the result that neuroticism personality trait is positively associated with dysfunctional attitude whereas extroversion, conscientiousness, agreeableness and openness traits are negatively associated among somatic symptom disorder patients. Consequently, Individual with neuroticism personality traits experience more dysfunctional attitudes and psychological health problems in comparison to individuals with extroversion, conscientiousness, and agreeableness and openness personality traits. Personality traits of somatic disorder patients are different from normal individuals. Results suggest that personality traits are associated with dysfunctional attitudes.