I like to think of medicine from a biopsychosocial perspective, which focuses on the bi-directional relationships between body, mind and environment. Note that I did not reference a brain-body, but instead a mind-body relationship. The 33 billion or so cells which serve as the command center of our nervous system is what we refer to as our brain. Our mind however is the complex of faculties enabling us to have subjective consciousness and intentionality toward our environment. That is to say, at a minimum, our mind affects our body and vice versa.
The last time you ended a stressful week at work with a stress headache, exacerbated stomach ulcer or common cold you may have been demonstrating what biosychosocial medicine calls somatic (body) symptoms of your psychological state. According to a study published last month in the Australian and New Zealand Journal of Psychiatry, somatic presentations of distress are common cross-culturally and are thought to predominate in Asian cultures such as that of China.
Let me say up front that the first two or three times that I read through this study, I was convinced that it was inappropriate to write about it here. I have always been a bit uncomfortable with using cultural observations to infer scientific conclusions - it strikes me as a hair’s breadth away from stereotyping.
However, after the fourth time through the reading, a particular statement in the conclusion paragraph caught my eye. “Overly broad generalizations concerning the somatization of distress in China are inaccurate and ineffective in explaining current trends.” I realized then that the authors were not creating a new oversimplification as much as they were deconstructing an old one. There was a ring of truth in their recognition that “cross-cultural portability of psychiatric theory is being replaced by a multifaceted perception of culture in which both local and global context of knowledge are examined”1 .
The method of this study was interesting in that the authors performed a literature search of PsychInfo and Pubmed in an effort to research the culture-specific factors associated with somatic symptoms in distressed Chinese subjects. The authors’ searches included terms such as Asia, somatoform, psychogenic and China.
One interesting conclusion suggested that there is such a stigma in China regarding mental illness, that patients would rather report bodily ailments, possible as a form of seeking help2 .The authors assert, for instance, that if we were to record the incidence of worldwide depression, then break down the numbers in a way that we could study them by geography, China’s statistics would be much lower than in other places3.
The disproportionately low depression rate, translates into a disproportionately high somatic rate. Even if the stigma did not exist to warp the numbers, an insufficient number of mental health care workers in China’s rural area suggest that the reporting of psychological symptoms would have to go untreated anyway.
Alexithymia was another topic that the authors touched upon. This is a differential diagnosis considered when a person is unable to describe their emotions with words. This condition could be caused by some kind of organic disorder in the brain, for instance biochemical or anatomical. More to the point of the study however, the condition might also be a coping mechanism used to deal with traumatic situations. While the former might be untreatable with current technology, the latter is reversible with psychotherapy and pharmacotherapy. The studying, citing a correlation between alexithymia and somatization mentions that individuals of Asian descent are less likely than those of European descent to report having had parents who verbalized positive emotions and displayed physical affection4, thus leading to a higher incidence of alexithymia.
From a history-of-medicine perspective, I was fascinated by one claim that disproportionate somatic symptoms in Chinese patients were due to the pathological condition neurasthenia5 , which is a defect in the structure of the nerves. The Chinese Classification of Mental Disorders uses the term neurasthenia as a diagnosis, presenting with symptoms such as headache, fatigue, anxiety and depressed mood. The term was used as early as 1829, the term was also used by the first educator to offer a psychology course in America, Dr. William James. Even though James claimed that Americans suffered so much from the disorder that he referred to it as “Americanitis”6 , the American Psychiatric Association no longer regards the term as an appropriate diagnosis.
Although the World Health Organization’s International Classification of Diseases parallels the Chinese Classification of Mental Diseases in referring to neurasthenia as a valid diagnosis, the study found that urban Chinese psychiatrists resist using the word because of increasing pressure to adopt a more westernized approach. On the other hand, practitioners outside of urban areas, specifically general practitioner continue to recognize the entity as a legitimate psychopathology in view that seems to agree with the study’s authors who maintain that “clearly, normative data specific to China needs to be utilized during psychological assessment.”
Zaroff1 C, Davis M, Chio P, Madhavan D, (2012) Somatic presentations of distress in China
1 Kirmayer, 2006
2 Parker G, Chan B, Tully L, et al. (2005) Depression in the Chinese: the impact of acculturation. Psychological Medicine 35: 1475-1483.
3 Chen CN, Wong J, Lee N, et al. (1993) The Shatin community mental health survey in Hong Kong. II. Major findings. Archives of General Psychiatry 50: 125-133.
4 Lee JW, Jones PS, Mineyama Y, et al. (2002) Cultural differences in responses to a Likert scale. Research in Nursing and Health 25: 295-306.
5 Kleinman A (1982) Neurasthenia and depression: a study of somatization and culture in China. Culture, Medicine and Psychiatry 6: 117-190.
6 Marcus, G (1998-01-06). “One Step Back; Where Are the Elixirs of Yesteryear When We Hurt?” The New York Times.
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