SOMATISED SYMPTOMS

BY Dr. Sanjiva Wijesinha

One of the potential public health effects in low to middle income countries is that as the standard of living of the population improves, healthcare services have to adapt to dealing with a range of problems.

They need to cope with communicable illnesses like bowel infections – diarrhoea, typhoid, hepatitis and amoebiasis; vector-borne transmission of diseases like malaria, dengue and chikungunya, as well as droplet borne ailments; in addition to chronic diseases like diabetes, heart disease and depression.

Depression is a condition that’s common in high income countries in the West. One reason for the under-diagnosis of depression in cultures like ours is the stigma associated with it – people suffering from depression veer towards denial of their emotional problems in favour of focussing on perceived physical illness.

Many patients with depression and anxiety who visit their general practitioners complain of bodily symptoms rather than volunteering information on psychological symptoms. Known as somatisation, it means the transfer of a feeling of unease or disease of the mind to a physical ailment of the body.

This phenomenon reduces the likelihood of a doctor recognising depression or anxiety in patients. In Chinese culture for instance, the word ‘depression’ is not in common use, and it’s normal for people to complain of physical symptoms like fatigue, headache, dizziness and pain rather than feeling low.

Stigmatisation of mental illness is also common in other societies. A 2004 cross-sectional research study by Ozmen, Ogel and Aker to ascertain public perceptions of depression in Istanbul found that a diagnosis of depression was viewed negatively. And depressed people were viewed as being ‘dangerous.’

It is not unreasonable to assume that in such societies, depression is underreported for fear of social exclusion. Even in the same country, people from different socioeconomic groups may have very different perceptions of depression.

A 2005 study by Alison Karasz in New York City found that immigrants from European countries had a more biological and medical explanation for the symptoms of depression compared to migrants from South Asia. The latter viewed symptoms of depression as a response to a difficult situation and were likely to refer to this as ‘tension.’

Somatisation is now recognised as a common problem in primary healthcare. It leads to the frequent use of medical services by patients, and adds to frustration in both the patient and doctor. Because their mental distress remains unrecognised and untreated, patients with somatisation are subject to long and costly investigations.

When we consult a doctor, the symptoms we present are affected by our culture and upbringing – we’re selective about what we tell our physician. We tend to describe symptoms that we believe are relevant and culturally acceptable.

Somatisation is sometimes called an ‘idiom of distress’ in cultures where psychiatric problems are associated with stigma, and the expression of emotional and psychological distress is inhibited.

We need to accept that depression is a disease like high blood pressure, asthma, pneumonia or dengue fever. These are diseases that can be treated – sometimes with complete remission and at other times, with therapy and/or medication that can control the condition so that the afflicted patient can lead a functionally normal life.