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SOMATIC PRESENTATIONS: CULTURE |
From the Department of Psychiatry (J.I.E.), UMDNJ-Robert Wood Johnson Medical School, Piscataway, New Jersey; and Department of Psychiatry (O.G.), University of Ibadan, University College Hospital, Ibadan, Nigeria.
ABSTRACT
Objective: To review international research on somatic presentations often seen together with or attributed to psychopathology. For conceptual clarity, we refer to these presentations as "idiopathic somatic complaints and syndromes" (ISCS). This review will also pose specific questions on cultural issues affecting these somatic manifestations.
Method: Selective review of the international literature dealing with the phenomenology, epidemiology, and cultural profile of ISCS focusing on papers published in refereed journals and written in English.
Results: Major problems with much of the previous research in this area are the use of different definitions and ascertainment procedures. As currently conceptualized in the literature, ISCS are universal and seem closely related to psychological issues (stress) and psychopathological conditions such as depression worldwide. Although there are many similarities regarding the form and content of these somatic presentations across cultures, there is some evidence for cultural patterning of symptoms. Unfortunately, current classifications for ISCS are unsatisfactory.
Conclusions: We outline specific recommendations for conducting future research and for improving the classification of ISCS of presumed psychological origin or import in future nosologies.
Key Words: somatoform disorders • medically unexplained physical symptoms • somatization • hypochondriasis • psychiatric classification • cross-cultural psychiatry
Abbreviations: ISCS = idiopathic somatic complaints and syndromes; SCL-90 = Symptom Checklist 90; GHQ = General Health Questionnaire; DIS = Diagnostic Interview Schedule; CIDI = Composite International Diagnostic Interview; SD = somatization disorder; AS = abridged somatization; NESARC = National Epidemiologic Survey of Alcohol and Related Conditions; ECA = Epidemiologic Catchment Area Study
INTRODUCTION
There seems to be a universal tendency to experience and communicate psychological distress in the form of physical symptoms and seek medical attention for them (1). In most cultures, these complaints and syndromes tend to be associated with increased medical visits, unnecessary medical tests, and the performance of procedures that may result in iatrogenic complications (2,3). There are many terms used in the literature to label these somatic presentations. These include "somatization symptoms," "unexplained symptoms," "medically unexplained symptoms," "functional somatic symptoms," "somatic presentations," "idiopathic physical symptoms," and many others. The association of these symptoms with psychiatric disorders follows the frequent coexistence of both types of phenomena and the evidence for psychogenesis in some instances. However, these symptoms most frequently arise spontaneously or stem from rather obscure, unknown causes. Moreover, what distinguishes these patients from others is not the symptoms per se but how they interpret them. For the purpose of this review, we felt it appropriate to use "idiopathic somatic complaints and syndromes" (ISCS) instead of some of the other terms listed above because many of the international studies discussed herein elicited the presence of physical symptoms that seemed to be medically unexplained but without clear reference to their etiology or pathophysiology (4). Besides bringing some conceptual clarity to the field, invoking the "idiopathic" label in this instance may fit current thinking in the psychosomatic field, such as the distinction of "neuropathic," "inflammatory," "nociceptive," and "idiopathic" pain (5).
In this selective review, we examine how these symptom presentations are distributed in different countries, cultures, and ethnic groups and we assess the impact of social and cultural factors on their form, frequency, and correlates. The main question we are trying to address is whether there are consistent and meaningful cultural differences in type and frequency of ISCS. In comparative studies, there is a need to clarify what exactly is being measured, and determine whether these studies are measuring the same thing. There is also a need to examine whether there is any evidence that these ISCS represent hidden psychopathology or serve a symbolic function in some cultures (idioms of distress). Finally, on the basis of this review, some recommendations will be made for future classification of these syndromes, in particular, how empirically validated cultural/social factors may be reflected in future diagnostic systems such as the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
Brief History
ISCS of presumed psychological origin have always mystified the medical establishment and taken new forms as cultures evolve and medical paradigms shift (6). Psychiatric syndromes with outstanding somatic manifestations, such hysteria and hypochondriasis, were key syndromes in traditional psychopathology and remained influential in medical discourse at the turn of the 20th century. As reviewed by Merskey and Mai (7,8), the idea that psychological processes are involved in certain somatic experiences seems to have ancient origins but waxed and waned periodically. In the 17th century, Sydenham was reputed to have ascribed not only pain and convulsions but diarrhea and dropsy to disturbance of the mind (9). In the mid-19th century, Briquet described a syndrome of multiple somatic symptoms to which he gave the name "hysteria" (10). Briquet gave an extensive clinical description of the syndrome, situating its origin in the brain and associating it with young women. Rightly or wrongly, Stekel (11) has been credited with the coinage of the term "somatization" but its entry into popular medical discourse is probably due to the work of Lipowski in the mid- to late-20th century (12). By the time "somatization" became a full diagnostic category in psychiatric classificatory systems, an extensive body of research, principally conducted in tertiary care settings of North America, had produced empirical evidence for the utility of its forebear, hysteria (13,14).
Phenomenology
The different symptom thresholds proposed throughout the years to elicit these syndromes, such as somatization disorder (SD), abridged somatization (AS), multisomatoform disorder, and other syndromes rely mainly on a number of symptoms presented (15). Psychological causation or modulation as well as behavioral and attitudinal aspects of these syndromes have been neglected in recent diagnostic systems possibly because they are difficult to define operationally. In an influential book, McHugh and Slavney (16) stated that somatic presentations (hysteria in this instance) "is not something the patient has; it is something the patient does; that is, it is a behavior."
Some useful models to practically dissect these ambiguous somatic syndromes have been recently proposed. For example, Brown (17) separated these symptoms according to three explanatory themes, namely, "dissociation, conversion, and somatization." Merskey and Mai (7) distinguished two types of somatic symptom presentations. The first comprises symptoms, such as unexplained pain and "functional" cardiovascular/gastrointestinal symptoms, which are involuntary, automatic, related to autonomic arousal, and manifest in temporal relationship to the experience of "stress" or jointly with depression/anxiety syndromes. This type seems particularly common in primary care. The other and more ambiguous set depends on thoughts, embodied intentions, or ideas that are not recognized or acknowledged, expressed as unexplained neurological symptoms. This subtype may represent the more severe, polymorphous, treatment refractory syndromes that are more likely to be seen in specialty mental health environments but are also seen in medical and surgical tertiary care centers. Although these models make sense intuitively, they have not been assessed in systematic studies. A recent European study showed that physical and psychological complaints are ubiquitous from an early age and that they seem to follow separate paths regarding their expression, evolution, and recognition (18).
Psychiatric Nosologies and ISCS
Despite the common joint occurrence of psychological and physical symptoms, patients with ISCS seem to focus selectively on the physical component and seem reluctant to accept a psychological etiology and even less a psychiatric diagnosis. This confronts clinicians with the often difficult decision of whether or not to attach a psychiatric label to a person with ISCS. Modern psychiatric nomenclatures, such as DSM-IV and International Classification of Disease (ICD)-10, have relegated somatic phenomena to a secondary level, and classify ISCS of presumed psychological origin under the heading of "somatoform disorders"—a category that is hierarchically inferior to other categories included in these nosologies (e.g., mood disorders). Although the creation of the somatoform category has been lauded as a nosological advancement by some investigators, in the "real world," patients with ISCS rarely fit neatly into the taxonomies provided by the DSM and ICD systems. Even when somatoform criteria are met, there is also significant overlap with several other psychiatric syndromes, a reminder that nosologies are still imperfect and in need of continuous distillation.
In classifying ISCS, the problems in applying current diagnostic criteria in primary care and community studies (e.g., the restrictive quality of categorical diagnoses that would leave out many of the "cases") led investigators in this field to propose the use of broad, dimensional categories as an alternative for research (15,19,20).
For example, in the late1980s, the senior author proposed an abridged construct of somatization (15), which has been found of value for international comparative studies. Also, in primary care, rather than categories, the use of dimensional constructs and concepts of somatization seems to have better utility (19,20). It would seem from current literature that there are two main dimensions, which may have practical value; one dimension is characterized by high levels of physical symptoms (somatization) whereas the other dimension is characterized by somatic amplification (hypochondriasis or health anxiety). In our view, this dimensional approach should be taken into account for future nosological revisions.
Epidemiology
Worldwide, a large majority of the comparative surveys that examined ISCS have consisted mainly of counts of physical symptoms with some effort made to rule out medical explanations (21–23). In these studies, the presence of high levels of ISCS has been generally derived from physical symptom inventories included in instruments, such as the Symptom Checklist 90 (SCL-90), General Health Questionnaire (GHQ), and particularly the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI). ISCS have been often articulated as either "full" or "abridged" somatization disorder. Problems with these studies include variations in key instruments, ways of survey administration, format of answers, and the reliance on lifetime rather than current symptoms. In general, ISCS have been reported to be more common among females, individuals from lower socioeconomic strata and in the US at least, among people from certain ethnic groups, such as Latinos. Also, the comorbidity of ISCS and psychiatric syndromes, such as depression, has been well documented for most cultures and ethnic groups, although there seems to be cross-cultural variation in frequency and severity of the associated physical symptoms.
General Populations
Studies in the United States, Puerto Rico, Germany, and Italy found lifetime prevalence rates of full SD ranging from 0.1% in the United States (24) to 0.8% in Germany (25) whereas lifetime rates of AS ranged between 5.6% in Germany (25) and 19% in Puerto Rico (21). Much larger prevalence rates have been reported for more broadly defined ISCS. For example, 22% of the general population in Germany reported at least one unexplained physical symptom leading to severe impairment (25), and in Switzerland, 80% of young adults reported sleep disorders, backache, headache, stomach or bowel complaints (18). However, these studies included various somatization criteria (ICD, DSM-III R, DSM-IV), different constructs, and concepts and they used different methodologies for assessment. Unfortunately, some of the most recent, large-scale, epidemiological studies, such as the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), either did not assess unexplained physical symptoms at all, or, such as the World Mental Health Surveys, assessed only chronic pain complaints (26), possibly due to the time and effort it takes to probe through long physical symptom inventories.
Primary Care
The primary care setting has been dubbed the "de-facto mental health system" and because this is more readily available across cultures than the more formal mental health system, comparative international studies have often taken place there. Studies in primary care are also of particular importance in regard to ISCS because physical symptoms at this level can be taken to have clinical importance to the person experiencing them. Overall, it has been estimated that, for as many as two thirds of patients presenting to primary care, no allopathic disease entity can be differentially diagnosed and unequivocally established as the principal determinant of a given patient’s presenting somatic complaints (27). In the US, our group reported a 3% prevalence of SD and a 20% prevalence of AS in patients presenting to primary care (28). In this study, immigrants to the US seemed to have higher rates of ISCS than the US born residents. We also found that about 20% of primary care patients had high levels of ISCS and that 75% of them met the criteria for a major psychiatric disorder, leading us to posit that ISCS may be the most typical way for common psychiatric disorders, such as depression and anxiety, to manifest in primary care. A study in Spain estimated that about 1/1000 of the population presenting to outpatient clinics met the criteria for full SD and about 20% met the criteria for AS (29). An international study sponsored by the World Health Organization (WHO) that took place in 14 different countries examined somatic symptoms as well as various concepts of somatization in primary care and how these related to depression and other syndromes (20,27,30,31). This study found that ISCS—defined as SD or AS—were very common (range = 53%–65%). Denial of psychiatric symptoms differed across sites with rates ranging from 3% in Brazil to 26% in Berlin. No major differences were noted across countries when somatization was defined as either denial of psychological symptoms or reporting of medically unexplained somatic symptoms. However, when somatization was defined according to presenting symptoms, they found greater variation among the centers. An important observation of this study was confirming that reports on lifetime somatic symptoms are unstable, particularly when somatic symptom thresholds are high (SD). Lower symptom counts (AS) fared better, but half of the symptoms reported at the initial interview were still forgotten 1 year later (31). According to this research, because diagnoses based on lifetime recall seem to rest on an unreliable foundation, the use of current rather than lifetime somatic symptoms should be considered for future endeavors. An important but poorly studied methodological issue is whether or not reported differences in rates of somatic presentations reflect "culture" as commonly conceptualized or rather, the nature in which the patient-provider interaction is conducted. ISCS may thus reflect the availability of particular health services in a given region. An indication that this may be the case stems from other findings of the previously cited WHO collaborative study showing that variation in the rates of somatization across sites reflects the way in which services were organized and provided in the clinics studied. Thus, there is some evidence that there are fewer "somatizers" in settings where more personalized type of care is common than in those where it is rare (20).
Culture-Specific Somatic Symptoms?
Clinical presentations dominated by physical symptoms have been suggested to represent "idioms of distress" and lay explanations embedded in culture concerning the origin of behavioral symptoms may play a relevant role in their form and intensity. These variations in symptom presentation are likely the result of the interaction of multiple factors within cultural contexts that affect how individuals identify and classify bodily sensations, perceive illness, and seek medical attention. Because physical symptoms are easy to scrutinize, they provide a useful construct for international comparison. Unfortunately, comparative studies have used different methodologies for symptom assessment and symptom thresholds. Assessment strategies have varied widely and the use of lifetime instead of current ISCS makes results of many studies questionable. According to the ICD-10 manual, the most common ISCS worldwide are gastrointestinal complaints and abnormal skin sensations. However, the type of symptoms representing "idioms of distress" may vary across cultural groups. In a review of the literature on cross-cultural aspects of somatization performed by the senior author (3), it was found that, in Latin America and the Caribbean, a repertoire of ISCS including dissociative features (trance, possession states) such as ataque de nervios, susto, el espanto, el duendeandother incubi, and mal de ojo have been described for many years and that high levels of ISCS have also been reported among Latin American patients with depression. The review also found that commonly reported somatic symptoms in Africa and India seemed to be different from those in Europe and the Americas. For example, common symptoms in Africa were "feeling of heat," "peppery and crawling sensations," and "numbness" and in India, they included "burning hands and feet" and "hot, peppery sensations in head" (3). In western countries, such as the USA, Canada, and Europe, there also seems now to be a tendency for patients to present with clusters suggestive of immunologically based disorders (2,32). The evidence, therefore, suggests that the type of somatic symptoms presented may vary across cultures. On the other hand, when identical ascertainment tools have been used, there are only very minimal and, albeit, inconsistent differences across cultures in regard to the frequency of ISCS. Thus, other than a tendency for much higher rates in Latin American sites, the WHO collaborative primary care study found no consistent differences in rates between sites in regard to the occurrence of somatization, hypochondriasis, or pain syndromes, however each of these was defined (20).
Type of Symptoms and Psychopathology
Unexplained physical symptoms mimicking neurological disease (previously called "pseudoneurological") seem to have a long tradition in psychopathology. They were the focus of the original construct of Hysteria/Briquet’s Syndrome (14). Studies employing cluster analytic methods have shown that high levels of these symptoms are a reliable marker for severe psychopathology. Thus, patients reporting high levels of neurological symptoms seem more likely than patients with other physical symptoms to meet the criteria for AS and SD as well as other Axis I disorders and to score higher on dimensional measures of depression, anxiety, and physical functioning. In addition, these patients are much more likely to meet the criteria for culturally related syndromes, such as ataque de nervios (33). A factor analytic study of somatization symptoms in a large primary care sample in Ibadan, Nigeria found that the factor with the highest Eigen value loading included a diagnostically important group of neurological (or conversion) symptoms, suggesting that these symptoms may have broad cross-cultural diagnostic utility (34). We believe that the presence of high levels of unexplained neurological symptoms should be taken into account in new classifications systems.
Somatic Symptom Clusters
Naturally occurring somatic symptom clusters have been characterized in community studies using data from the Epidemiologic Catchment Area Study (ECA) and the Puerto Rican Epidemiologic Survey employing statistical clustering techniques. However, a "unique" somatic symptom factor that included abdominal pain, nausea, vomiting, excessive gas, dyspnea, chest pain, palpitations, unusual spells, amnesia, paralysis, dizziness, fainting, and muscle weakness was found exclusively among Puerto Rican respondents (35). Interestingly, the clinical manifestations of ataque de nervios (headache, trembling, heart palpitations, stomach disturbances, a sensation of heat rising to the head, numbness of extremities, and at times, pseudo seizures, fainting, and unusual spells) look strikingly similar to those symptoms included in the symptom cluster derived from the epidemiological sample in Puerto Rico (36).
CONCLUSIONS
In responding to the specific queries posed at the outset, this brief review has shown the following:
We wish to add the following caveats:
In closing, we strongly recommend that in developing and assessing new diagnoses relevant to ISCS, those working in the mental health field should maintain a close collaboration with many other international colleagues as well as members of key disciplines, such as general health and primary care.
NOTES
Partially Supported by Grant P20MH074634-01 from the National Institute of Mental Health.
Received for publication January 26, 2007; revision received August 6, 2007.
This article is being co-published by Psychosomatic Medicine and the American Psychiatric Association.
DOI:10.1097/PSY.0b013e31815b007e
REFERENCES
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