SOMATISATION AND SOMATIC NEUROSIS - CROSS CULTURAL VARIATIONS

INTRODUCTION

Somatisation refers to the occurrence of physical symptoms, which are not accounted for by demonstrable physical illness. Such symptoms are extremely common and do not necessarily indicate psychopathology (Lipowsky, 1986). They do become a psychiatric problem, however, when individuals who are so disposed attribute their somatic symptoms and distress to physical illness and repeatedly seek medical help for them. somatisation has been described to be a universal phenomenon. However, the contextual meanings of somatic presentations are largely shaped by factors, which are specific to individual cultures. In some cultures, somatisation is understood as having a neurotic basis.

NEUROSIS AND somatisation: ORIGINS AND CONCEPTS

The term neurosis was coined by Cullen in 1769 to refer to `disorders of sense and motion' caused by a `general affection of the nervous system'.

Over the last two centuries, this term has evolved to be used in at least four different but related ways -

i) as a global term to indicate all nonpsychotic conditions,

ii) as a term to indicate specific neurotic disorders like anxiety, depression, etc,

iii) as a term to describe assumed underlying defense mechanisms,

iv) as a maladaptive pattern of behavior (with some evidence of anxiety) following a stressful life situation, which tend to avoid responsibility and the stressful situation itself (Freeman, 1993, Chaturvedi 1992).

Current classificatory systems have, however, abandoned the category of neurosis as an organizing principle. In the ICD-10, disorders regarded as neurosis remain together, but under the rubric of `neurotic, stress related and somatoform disorders', while the DSM-IV has eliminated the category altogether. Disorders considered to be neuroses are now described under heads of anxiety and depressive disorders. The usage of the term neurosis has become controversial, but it has been argued that a more appropriate term is needed to replace it. More has been written about schizophrenia and depression across cultures than about neurotic disorders. Certain types of neurotic disorders have also received cross-cultural attention. The acknowledgment and acceptance of the concept of somatisation has altered the main scenario of neurosis. To an extent, somatisation has influenced our understanding of neurosis in the cultural context. Various investigators have studied the influence of culture on somatisation - in terms of epidemiology, clinical profile and course. somatisation had been proposed initially as a psychodynamic construct but is now conceptualized as a pattern of illness behaviour, in which somatic symptoms are presented to the exclusion of emotional distress and social problems.

For research purposes, somatisation has been operationalised in three main ways -

i) as medically unexplained physical symptoms,

ii) as hypochondriacal worry or somatic preoccupation, and

iii) as a somatic presentation of anxiety and other disorders (Kirmayer and Young, 1998).

The ICD-10 and DSM-IV however, include primary somatizing states under the rubric of somatoform disorders, wherein patients have persistent physical symptoms despite reassurance that there is no physical explanation for the same and thus causing some degree of impairment in social and familial functioning. It has been traditionally believed that somatisation occurs predominantly in non-western and developing societies and among ethnic groups in the West. Early reports from Africa, India and China pointed out that in those cultures, certain psychological disorders, such as depression and anxiety, presented mainly with somatic symptoms. The possible association of somatisation and socio-cultural factors interested a number of researchers who proposed a variety of terms, clinical concepts and theoretical models to explain the same. People from lower socio-economic and illiterate backgrounds were considered to lack adequate linguistic or psychological sophistication to communicate their feelings verbally, and therefore, somatize their emotional distress (Chaturvedi, 1993; Issac et al, 1996). The term `alexithymia' was coined to describe this constriction of emotional functioning, accompanied by a limited and lackluster fantasy life. Other cultural factors implicated in somatisation include the lack of appropriate, specific words for a variety of emotions in many languages (e.g. Farsi in Iran). Expression of one's feelings overtly is regarded as an admission of weakness, and hence, socially undesirable in some Asian cultures. Deleterious social consequences of psychiatric labeling and stigmatization may prevent reporting of emotional distress in such cultures. Illness behaviour and adoption of a sick role to achieve a variety of social and personal objectives has also been proposed to describe somatisation. Thus somatisation is considered to be an alternative to the overt expression of emotional distress and is inversely proportional to it.

SOMATISATION IN THE WEST:

Research over the last two decades suggests that though the prevalence and specific features of somatisation may vary across cultures, the processes of focusing on, amplifying and clinically presenting somatic distress are universal and somatic symptoms are the most common clinical expression of emotional distress worldwide. The National Ambulatory Medical Care survey in the United States found that 70% of patients with a psychiatric illness present with a somatic complaint (Schurman, et al, 1985). In the United Kingdom, Bridges et al. (1991) found that over half of the patients with diagnosable psychiatric disorders that they studied in Manchester sought help for somatic symptoms. The WHO cross-national study of mental disorders in primary care found a high prevalence of somatisation across all the 15 centers though rates varied markedly. Levels of somatic symptomatology and emotional distress were highly correlated at all the sites, thus suggesting a linear relationship between somatic symptoms and overt psychological expression of distress (Ustun and Sartorius, 1995). A recent study by Kirmayer and others found that there is a tendency for some specific ethno-cultural groups in the same urban milieu and with equal access to health care, to use health care services almost exclusively for somatic symptoms than for psychosocial distress (Kirmayer, 1984). This suggests that culture influences the clinical presentation of somatic symptoms in some ways. somatisation in Western countries has been described primarily in a phenomenological fashion and is termed as somatisation disorder in international classifications. Thus, in the West, chronic physical symptoms involving at least four organ systems beginning before the age of 30 years and resulting in social and occupational impairment is somatisation disorder. Such a conceptualization ignores the large number of subthreshold cases who have brief lasting symptoms often in relation to stressful situations and do not involve four systems, and present to primary care settings in many developing countries.

SOMATISATION IN THE EAST - IS THERE A SOMATIC NEUROSIS?

It has been observed that there is a group of neurotic patients in psychiatric clinics in India presenting predominantly with multiple somatic symptoms and coming from certain distinctive socio-cultural backgrounds. They are characterized by some consistent clinical features: chronicity, a mixture of pronounced anxiety and depression, and an ill-sustained response to treatment, against a background of poorly verbalized long- standing life stresses.

Such a presentation was most characteristically seen in the Muslim women who were from lower socio-economic group and were in their thirties or forties. Gautam (1976) mentioned that at the National Institute of Mental Health and Neurosciences, Bangalore, India, it was `felt by most of the psychiatric consultants that most of the muslim patients (particularly females) presented with a peculiar group of somatic complaints such as headache, chest pain, pain in all the extremities, palpitations and weakness... most of these symptoms were essentially present in most of them.' The term `somatic neurosis' was coined for this syndrome pending resolution of its nosological status (Janakiramiah and Subbakrishna, 1980).

Janakiramiah and Subbakrishna (1980) conducted a study among twenty women with somatic neurosis and compared them with an equal number of women with depressive neurosis and anxiety neurosis. They found that women with somatic neurosis were significantly different from the comparison groups in terms of anxiety, depression, stress and illness duration factors. The existence of this syndrome as a fairly distinct entity is further supported by clinical experience in various psychiatric clinics in India, where it is frequently referred to by such terms as `Jama Masjid Syndrome' and `Haathan Pairaan mein dard syndrome'.

A subsequent study by Janakiramiah, (1983) found that the syndrome of somatic neurosis was not confined to muslim women and that it occurred among middle aged women of other communities as well. These patients were found to differ from neurotic depressives in having lower depression scores and better interpersonal trust. It is difficult to include this syndrome of Somatic neurosis in any definitive diagnostic category in current classifications because of the following reasons. Firstly, despite several somatic complaints, the picture is not dominated by an excessive concern with ones' bodily health. There is frequently a disparity between the patient's complaints and behavioural appearance. Also the patient frequently lacks settled conviction or consistency in symptoms. Secondly, these patients exhibit mixtures of anxiety and depressive symptoms in addition to somatic complaints without any one cluster appearing to dominate, and hence not fitting neatly into any existing diagnostic category. They also readily report life stresses though they donot always correlate them with symptoms. Thirdly, there are frequent shifts in the symptoms in relation to changing life circumstances. Many times, the clinical presentation of somatic symptoms occurs only in the context of stressful situations and may thus reflect a mode of coping with these situations. Also, the symptoms begin after the age of 30 years and may involve less than four organ systems. For these reasons, this cluster of symptoms differs from the category of somatisation disorder in the DSM. No other satisfactory term has emerged for this group of patients in current classifications despite the functional distress experienced and burden on health economy incurred.

Viewed from a socio-cultural perspective, patients with somatic neurosis mostly hail from lower socio-economic and lower educational backgrounds wherein freedom of expression and mobility in society are restricted. There are also long-standing stressors in financial and family related spheres. In this context, somatic symptoms constitute a neurotic coping mechanism to deal with societal inhibitions. Here, the whole process of experiencing and reporting somatic symptoms and seeking help for them repeatedly affords a temporary release from culturally and socially enforced secluded lifestyles. Thus, a woman who stays at home and manages the household everyday of her life, gains an opportunity to get the attention of other family members, to be relieved of routine responsibilities and also travel out of home for purpose of medical consultation. It is not just the experience and reporting of somatic symptoms, but the repeated help-seeking abnormal illness behaviour (Pilowsky, 1969) which is neurotic and maladaptive. In a way, it is an idiom of distress, which seeks help. These idioms of distress are ways of communication of distress based on cultural norms, practices and beliefs which are in turn based on their cultural perception or misperception (Nichter, 1981). somatisation serves to avoid stressful life situations at home and gain a legitimate entry into the sick role. Similar disorders are noted in young men from the Indian subcontinent who present with dhat syndrome (Malhotra & Wig, 1975), and also in women who report somatic and neurotic symptoms related to passing of innocuous vaginal discharge (Chaturvedi, 1988; Chaturvedi et al, 1993). These aspects of somatisation in a certain population of the Indian subcontinent lend credence to somatic neurosis being a distinct entity and therefore warrants further studies as to its validity.

CONCLUSIONS:

somatisation is a ubiquitous phenomenon but its prevalence and clinical characteristics vary considerably across cultures. In India, a group of neurotic patients belonging to a distinctive socio-cultural background presenting with a chronic and predominantly somatic multiple symptomatology against a background of poorly verbalized long-standing stress has been identified and the term somatic neurosis coined for their illness. This syndrome has fairly distinctive characteristics but does not fit neatly into current classifications. The socio- cultural background of these patients gives a meaning to their clinical presentation. The management of such somatic neurosis needs special attention and care to the sociocultural factors. The distinctive features of this syndrome merit further studies as to its validity.

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