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Ann Rheum Dis 2001;60:653–657
653
HYPOTHESIS
Breast implants and illness: a model of
psychological factors
D M Dush
Abstract
Studies of disease outcomes have not produced an explanation or an intervention
for the symptoms and complaints that
some women have attributed to breast
implants. Reviews of the literature have
found no increased risk of specific systemic disease, and no treatment recommendations have emerged. However,
similar symptoms in fibromyalgia,
chronic fatigue, and other contexts have
been considered to be stress or behaviourally mediated, and a number of promising
behavioural interventions have been developed. Aetiological, research, and treatment implications may follow from the
consideration of such symptoms within a
behavioural medicine model that allows
for the interaction of physical and psychological influences. In the case of implants,
a mass somatisation model may also help
to discern the potential eVects of litigation
and other social influences.
(Ann Rheum Dis 2001;60:653–657)
Department of
Psychology, 118 Sloan
Hall, Central Michigan
University, Mt
Pleasant, MI 48859,
USA
D M Dush
Accepted 23 January 2001
Since the beginning of the breast implant
controversy, a host of symptoms have been
attributed to implants. Concerns have included
(a) systemic diseases and conditions such as
cancer or connective tissue disease, (b) nonspecific complaints such as fatigue and pain, and
(c) local complications such as capsular contracture, rupture, or infection. It has not been
disputed that local complications can occur.
However, systematic studies have found no consistent risk of systemic disease associated with
implants (see example studies and reviews1–8).
Some women with breast implants have systemic diseases, but epidemiological research
suggests that the same proportion of women
without implants have these diseases. This conclusion has been supported by summary comments of the American Academy of Neurology,9
the Institute of Medicine,10 and an expert panel
convened by United States Judge Pointer.11
None the less, many women continue to
complain of symptoms that they attribute to
implants. Reviews of symptom complaints are
scarce. Most epidemiological studies have
focused only on systemic disease outcomes,
providing limited published information on
individual symptoms or complaints. The symptoms investigated have varied widely with the
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Table 1 Symptoms reported by women with implants in
Tugwell’s review12
I Symptoms reported anecdotally by women without specific
connective tissue disease, but with no controlled studies
Allergies
Muscle cramps
Bruising easily
Nausea/vomiting
Heartburn/oesophageal
Night sweats
Chronic inflammation
Pain
Cognitive/memory
Sensitivity to heat/cold
Coughing
Sleep disorders
Decreased sex drive
Sore throat
Diarrhoea
Temporomandibular joint
problems
Flu-like feelings
Tender points
Heart palpitations
Urination—burning
Hot flushes
Urination—frequent
Incontinence
Urination—incontinence
Infections
Vision—blurred
Malaise
Vision—photosensitivity
II Controlled studies showed no evidence of significant group
diVerences for these symptoms for women without specific
connective tissue disease
Alopecia
Anxiety/panic
Breathing problems
Mucosal ulcers
Shortness of breath
Muscle weakness
Pulmonary symptoms
Neurological deficits
Chronic fatigue
Paraesthesias
Low energy
Swallowing/dysphagia
Concentration problems
Swelling/bloating
Constipation
Vertigo/dizziness
Low grade fever
Ringing in ears/vestibular
Headaches
Weight gain
Mood swings/irritability
Weight loss
III Controlled studies with inconsistent group diVerences: one
or more but not all studies reported significant group
diVerences
Pain in joints
Swollen/tender glands
Muscle pain/fibrositis
Dry eyes/mouth/skin/vagina
Skin changes/hives/rashes
StiVness
IV Controlled studies finding consistent group diVerences in
symptoms reported by women with implants
None
type of disease studied and method of study.
Tugwell’s review12 is especially helpful, as it
examined symptom complaints from studies of
women with implants who did not meet the
criteria for specific connective tissue diseases.
It also summarised symptoms from anecdotal
case reports. Table 1 shows that a wide range of
complaints have been reported by women with
implants, though no consistent diVerences
between women with implants and controls
have been found.
Overlap of non-specific symptoms
Several researchers have noted that complaints
of women with breast implants appear to overlap with a pool of symptoms common among
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654
Dush
disorders, such as fibromyalgia, irritable bowel
syndrome, and chronic fatigue syndrome.13–15
Barsky and Borus postulated that side eVects
attributed to breast implants are one of several
related functional somatic syndromes characterised by symptom amplification, suVering,
and disability in the absence of, or disproportionate to, demonstrable tissue abnormalities.13
They propose that this spectrum of syndromes
includes sick building syndrome, repetitive
stress injury, Gulf War syndrome, and chronic
whiplash. Similarly, Winfield suggested that
most women with breast implants complaining
of silicone induced atypical connective tissue
disease actually have fibromyalgia and that
fibromyalgia is not a disease, but part of a
spectrum of related conditions with similar
aetiologies and pathologies.14
It is instructive to compare the symptoms of
fibromyalgia, for example, with the complaints
commonly identified by women with implants
noted in table 1. Widespread pain, multiple
tender points in specified locations around the
body, persistent sleep disturbance, and fatigue
are also considered central to the diagnosis of
fibromyalgia.16 Many other symptoms may be
associated—for example, allodynia, hyperalgesia, subjective weakness, dysaesthesias, paraesthesias, complaints of memory and concentration problems, auditory, vestibular, and ocular
complaints, chronic rhinitis, complaints of
allergies, heart palpitations, superimposed regional pain syndromes, such as headache,
atypical chest pain, pelvic pain, dyspareunia,
temporal mandibular disorder, or myofascial
pain, irritable bowel symptoms, subjective joint
swelling,14 Raynaud’s phenomenon, premenstrual tension, irritable bladder, migraine
headaches,17 and symptom aggravation by
stress.18 Considerable overlap with table 1 is
apparent.
Behavioural medicine and somatisation
In this spectrum of disorders with overlapping
symptoms and no specific known cause psychological contributions are often suggested
and behaviourally based symptomatic treatments commonly applied.1 19 However, until
recently, psychological models have received
little attention in conceptualisation of the complaints reported by women with breast implants. The present hypothesis is that somatisation may be an important factor in
understanding and treating a portion of the
complaints reported by individual women with
implants. Mass somatisation, in turn, may further explain the social phenomenon of large
numbers of people reporting similar symptomatic shifts and changes in tandem with public
events, mass media coverage, mass litigation,
and public policy changes.
Somatisation is a common term but one
used in varied ways. It has often implied that
symptoms are psychological or imaginary
rather than physical and real. The present view
of somatisation refers to:
+ Psychological initiation of actual physical
symptoms or dysfunction
+ Psychological intensification of actual physical symptoms
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+ Psychological magnification or perception of
benign sensory phenomena as distressing or
symptomatic
+ Reattributions of the cause and meaning of
physical and psychological symptoms
+ Altered response to physical symptoms at an
emotional, social, behavioural, and cognitive
level
+ Reciprocal interactions of all of the above.
This assumes that one may aVect many
physical symptoms and sensations through
stress, classical conditioning, operant conditioning, and other cognitive and behavioural
mechanisms. In this broader sense it is likely
that all people experience some elements of
somatisation.
Drawing heavily upon the integrative model
of Kirmayer and Taillefer,20 there appear to be
eight primary facets of the somatisation
process, all of which may occur simultaneously
and interactively.
BASELINE
The individual begins with a pool of various
sensory input and perceptual interpretations at
various levels of subclinical intensity, as well as
specific medical symptoms and diVuse or
unexplained medical symptoms. Raised baselines of diVuse or vague symptoms or sensory
phenomena may represent an initial risk factor
for somatisation.
BASELINE CHANGE
Emotional arousal, psychological disturbance,
medical illness, stress, psychiatric disorder, or
other factors may change baseline response by
increasing symptoms, changes in thresholds,
hypersensitivity to sensory phenomena, hypervigilance, or other changes in the physiology
itself. A common end point is increased attention to bodily sensations. As focused attention
alters the signal to noise ratio in sensory
phenomena, the result may be an actual
increase in the perceived intensity of various
sensory inputs.
ATTRIBUTION
The perceived meaning of symptoms and any
changes in physiology, sensation, or perception
are critical. Most often with somatisation there
is an attribution of sensations and changes to
disease or illness. Other cognitive variables may
play a part in this initial attribution process,
such as predictability of and perceived control
over threat.
INTERNAL MEDIATION
Individual coping responses further shape the
response to sensory phenomena and symptoms. People inclined more toward worry,
catastrophising, depression, or demoralisation
may have more adverse responses. Those with
a history of somatoform disorders may be at
higher risk. Comorbid maladaptive personality
characteristics, personality disorders, or other
specific disorders, such as post-traumatic stress
disorder, may pose added risk.
SOCIAL MEDIATION
The social context has an important role,
including the response of family, healthcare
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655
Breast implants and illness
WIND UP
Somatisation is prone to feedback loops, where
responses in any one facet of this cycle may fuel
changes in others. For example, stress may
cause new physical symptoms or intensify
existing ones. Increased symptoms, in turn,
add more stress and increased wariness of normal physical sensations, aVecting the judgment
of normal versus abnormal sensory input.
CONSOLIDATION
Although normal somatisation phenomena are
likely to be transient, those that lead to illness,
suVering, and disability become entrenched.
An array of consolidating factors may be
important in this entrenchment process: (a)
There may be contingencies that interfere with
resolution, such as litigation, other counterincentives, or face saving issues. For example,
people who have become convinced that their
suVering and symptoms are due to a certain
medical cause may be reluctant to reconsider
these as attributable to their own coping skills
and response to stress. (b) The reciprocal influences of wind up may perpetuate the process
and reinforce sustained hypersensitivity or
hypervigilance. For instance, Okifuji and Turk
have suggested that patients with fibromyalgia
develop a generalised hypervigilance that
promotes generalised somatic symptoms as
well as related elements such as doctor
shopping, inconclusive diagnostic results, increased emotional distress, symptom magnification, feelings of hopelessness, change in
social dynamics, and abnormal illness behaviours.19 (c) Help seeking responses and coping
skills are likely to be pertinent. Changes may
begin to develop over time in one’s basic
approach to the problem. Avoidance of cognitive dissonance may lead individual subjects to
disregard alternative explanations. Once disease conviction reaches a certain level, reassurance becomes more diYcult or paradoxical.
For example, it has been suggested that
participation in support groups and access to
inflammatory patient information may make
non-specific complaints worse.22
ADAPTATION AND TERTIARY IMPACT
Some people are inclined towards problem
solving and others towards adaptive coping
styles, which probably helps them to move forward and away from the cycle of somatisation
and entrenchment. Others may be more
vulnerable to progressive disability or persistent suVering and disease preoccupation. Persistent somatisation may actually alter physical
symptoms and create new medical problems—
for example, the immobilisation and progressive physical decline characteristic of patients
with long term chronic pain.
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Mass somatisation
Jones, Craig, and colleagues define mass
psychogenic illness as widespread subjective
symptoms attributed to presumed toxic exposure in the absence of objective evidence of a
specific cause.23 As we have suggested with
somatisation generally, Wessely has noted that
mass psychosomatic symptoms “Are physiologic experiences that are based on identifiable physiologic processes that cause pain and
suVering” (p 129), with the potential to
develop into long term chronic illness.24
Winfield suggested that complaints associated
with implants, as well as disorders such as
fibromyalgia, chronic fatigue syndrome, sick
building syndrome, and multiple chemical sensitivity syndromes, are at least partly attributable to social and attributional factors commonly associated with mass somatisation, such
as media attention, hype, suggestible fears, and
the eVects of product liability and litigation.14
Although there have long been reports of
mass psychogenic illness,25 26 such social phenomena are diYcult to study under controlled
conditions. Careful case studies do suggest a
natural history that follows a somewhat predictable course (fig 1): (a) Initially, some people appear to be more susceptible, and may
share one or more risk factors at baseline.26
These may include stressful life circumstances,
low control over the perceived threat, a higher
than normal baseline pool of initial physical
symptoms of unknown origin (particularly
symptoms that are stress related or suYciently
ambiguous to allow reinterpretation or reattribution), personal traits and circumstances that
favour emotion focused rather than problem
solving strategies, low or dysfunctional social
support, and higher rates of pre-existing health,
interpersonal, and psychological problems. (b)
An initial threat and possible set of symptoms is
identified. (c) Concern and awareness spreads,
d
Morbidity
providers, employers, litigation environments,
the media, and the insurance or compensation
system. In the case of implants, individual and
social aspects of cosmetic surgery and body
image may be particularly relevant.21
c
e
a
f
b
Time
Figure 1 Mass psychophysiological phenomena are
assumed to aVect large groups and share key features: In
the normal course (a) a baseline of diVuse symptoms and
risk factors, (b) initial perceived health threat, (c) diVusion,
with increased incidence and severity of symptoms as
concern spreads, (d) point of maximum diVusion and
average morbidity, (e) trend reversal with decreasing
prevalence and severity in response to decreased threat and
reassurance, and (f) return to baseline.
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656
Dush
and the prevalence and severity of symptoms
escalate. This may be accelerated if authorities
pronounce these as a new syndrome or disease.
(d) DiVusion of threat and incidence of
complaints peak. (e) Complaints diminish in a
recovery process as potential threatening
causes are credibly eliminated. In smaller communities, it has often been the trusted, well
informed family doctor who has a key role in
this reassurance and reattribution. (f) Eventually, concerns return to baseline.
Some aspects of the response to implants
may reflect mass somatisation, and there are
several points that might have particular
relevance: (a) The baseline pool of diVuse
physical symptoms might have been larger than
average for women with complaints attributed
to implants. Medical devices and procedures
may represent extra risks for mass somatisation
by nature of the high invasiveness and low personal control involved. Recent studies have also
suggested that women, in general, may have a
higher rate of diVuse baseline medical symptoms and complaints—for example, higher
incidences of diVuse muscle pain, irritable
bowel syndromes, and chronic fatigue.18 27
Also, the medical and psychological histories of
women who seek breast augmentation appear
to diVer from those of other women, and
cosmetic surgery, generally, may alter social
support, coping, and information seeking
mechanisms.28 (b) Spread of concern about
implants might have been accelerated and prolonged by mass media and early high profile
litigation. (c) Modern media distribute concerns so broadly, geographically, so quickly,
that normal self limiting or corrective forces
may be less eVective, and perceived threat more
diYcult to define and contain. (d) The United
States Food and Drug Administration moratorium placed upon silicone gel-filled implants
might have increased the atmosphere of potential threat. (e) As a result of all of the above the
return to baseline might have been more sluggish and frequently interrupted. (f) As large
numbers of people enter litigation, certain psychological factors become more salient. Litigation adds counterincentives to recovery,
though these are probably subconscious rather
than deliberate.2 Claimants are likely to be
evaluated by plaintiVs’ experts who may
reaYrm their fears of disease and threat.
Claimants may also be counselled by attorneys
and support groups who further stimulate their
fears. We have also found, in samples of
patients with chronic pain, that those in litigation tend to (a) report more symptoms,
particularly obvious rather than subtle clinical
symptoms used for diVerential diagnosis, or (b)
favour physical rather than psychological explanations for symptoms.29 These may be
selectively symptoms that are more easily reattributed to injury related concerns.
Treatment implications
If even some of the symptoms associated with
the complaints of people with implants can be
attributed to somatisation, stress, mass somatisation, or other psychophysiological responses,
then there may be important implications for
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treatment. Little in the way of intervention has
emerged, to date, from the focus of epidemiological studies upon disease outcomes. Because
these studies conclude that there is no reliably
increased risk of specific diseases for women
with implants, there generally is no next step
proposed for intervention. However, somatisation, as presently proposed, produces real
symptoms, interacts with other real symptoms,
and may produce high levels of morbidity.24
Clearly, a careful study of possible intervention
models is needed.
Barsky and Borus suggest guidelines for
medical management of potential somatisation
phenomena13:
+ Approach patients presenting with these
types of complaints with careful medical
examinations to rule out specific disease, yet
avoid tests solely for the purposes of
reassuring the patient, to avoid iatrogenics
that may enhance the sick role or reinforce
the conviction that the patient has some
unknown biomedical disease
+ Evaluate for the presence of psychiatric disorders and yet reassure the patient that this
does not mean that the cause of symptoms is
imaginary
+ A collaborative therapeutic relationship is
crucial, in which the patient feels that their
suVering is understood
+ The emphasis should be upon coping and
rehabilitation to improve functioning and
reduce impairment. Reilly similarly emphasises that patients must be helped to become
more active in managing their symptoms by
eVorts such as exercising, losing weight, or
practising stress management22
+ The process of symptom amplification
should be explained, as well as the interactive roles of psychological factors and symptoms more generally
+ If problems persist, formal cognitive behavioural treatment should be prescribed.
Review of related publications is encouraging about the potential benefit of application of
cognitive behavioural psychological interventions. These interventions generally include a
combination of structured, directive techniques targeting relaxation training, stress
reduction, facilitation of more normalised
activity, and alteration of negative or anxiety
promoting thinking patterns. Barsky and Borus
cite considerable reports that show potential
benefit from cognitive behavioural treatment
for various somatic symptoms, including those
associated with irritable bowel, fibromyalgia,
and chronic fatigue syndrome.13 Similarly, a
review of 49 treatment outcome studies of
behavioural interventions for fibromyalgia concluded that the combination of drug treatment,
cognitive behavioural therapy, and exercise
produced the most favourable outcomes,30 and
a recent review of treatments for chronic
fatigue syndrome found that cognitive behavioural interventions have been shown to
increase patients’ level of functioning.31 In view
of the symptom overlap, eVective intervention
protocols from these related publications may
hold promise for treatment of complaints associated with implants.
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657
Breast implants and illness
Conclusions
Several concerns should be acknowledged.
Firstly, there are essentially no direct tests of
the presumed eVect or treatment of somatisation processes in women with breast implants.
I am relying heavily upon comparisons of
symptoms with those of other disorders and
other circumstances. Controlled studies to test
these assumptions are clearly needed. Secondly, there are likely to be symptoms that fall
outside this model—for example, the specific
local complications of breast implants that
occur in a proportion of cases. There are also
clearly women with implants who have a
variety of coincidental specific diseases not
caused by implants.
None the less, we may be able to reduce distress and morbidity among women with
implants by taking a broader viewpoint. Large
scale health related fears, accusations, and litigation have substantial psychological aspects.
Psychological aspects may even be suspected to
be the dominant forces when there is no
specific physical cause or when the morbidity
exceeds what might be expected from a specific
physical agent. This is especially true in disorders that have a strong social component, such
as those cases in which a large group of people
begin to present with similar new patterns of
subjective complaints, or when mass tort or
mass media hype is involved. In such instances,
a model of mass somatisation eVects may help
to guide towards timely intervention, research,
and prevention.
Litigation over breast implants may continue, but regardless of the presence, absence,
or size of settlements, there are women who
continue to struggle with unexplained symptoms and worry about the implications for their
health and their future. Reassurance is often
not suYcient, and the litigation climate surrounding implants may counteract reassurance
eVorts that otherwise would be suYcient.
Residual complaints, psychological and psychophysiological, should not be dismissed as
imaginary, unimportant, or factitious without
evidence. Existing methods of treatment for the
broader spectrum of somatisation and stress
related disorders, combined approaches to
behavioural and medical rehabilitation, and the
development of new interventions tailored to
women with implants, warrant serious consideration.
Based upon a paper presented at the annual meeting of the
Society for Behavioral Medicine, San Diego, USA, 1999. I thank
Dow Corning Corporation for its support. Dr Laura Perkins, Dr
Ralph Cook, Dr Patti Klein, Dr Susan Hoshaw, Dr Steve Bowlin, and their associates have provided helpful comments on
earlier versions of this work.
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Breast implants and illness: a model of
psychological factors
D M Dush
Ann Rheum Dis 2001 60: 653-657
doi: 10.1136/ard.60.7.653
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