Hong Kong Journal of Psychiatry (1995) 5, 52-57

ORIGINAL ARTICLE

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INTRODUCTION

Somatization, broadly defined, is the presentation of one or more medically tu1explained somatoform symptoms (Mayou, 1993), The DSM-Ill (American Psychiatric Association, 1980) created a category of Somatoform Disorders in an attempt to define the different illness patterns subsumed under the phenomenon of somatization, and th.is category has been retained in the DSM-III-R and DSM-IV systems. Although this effort has been criticized for over-emphasizing the psychiatric con-elates of tu1explained medical symptoms on which little data or W1derstanding exist (Mayou, 1993), it makes eminent sense to study medically tu1explained somatoform symptoms from a psychiatric perspective, because there are several mechanisms that may explain the association of psychiatric disorders and medically tu1explained somatoform symptoms. Among the possible mechanisms suggested for th.is association are: shared underlying physiological or neurobiological disturbances, amplification of physical sensations by psychiatric disorders, and exacerbation of psychiatric symptoms by chronic physical symptoms (Katon et al., 1991).

In the DSM-IV (American Psychiatric Association, 1994), there are seven disorders included W1der the category of Somatoform Disorders. TI1ey represent conceptually distinct, although overlapping, illness patte111S. Kirmayer and Robbins (1991) have identified three patterns: (1) high levels of medically tu1explained somatoform symptomatology; (2) hypochondriacal worry; and (3) somatic presentation of a psychiatric disorder.

Much of the recent research has focused on Somatization Disorder (SD) (for review see Cloninger, 1986; Robins et al,, 1984; Swartz et al., 1991), a disorder that presents with high levels of medically tu1explained somatoform symptomatology.

There is also some research into the area of somatic presentations of psychiatric disorders. After a detailed review of somatoform presentations of psychiatric disorders in different cultures, Leff (1988) concluded that the psychological mode of experiencing distress is predominantly a recent, Western phenomenon. He believed that social changes in the West have resulted in greater introspection, more open and verbal expression of distress particularly outside the family, and a shift in the focus of emotional experience from the body towards the psychological mode. Studies have follh<l level of somatoform symptomatology to vary with gender, education level, ethnicity and location of residence (for review, see Swartz et al., 1991), i.e., diagnosable and subsyndromal Somatization Disorder is culturally and subculturally related.

Other researchers (e.g., Tseng, 1975; Gaw, 1993) have suggested that in the Chinese culture, somatoform symptoms may be the predominant presentation of a psychiatric disorder, particularly Major Depression. Kleinman (1986) described a consecutive series of 100 patients in a city in the province of Htu1an, China, who were given a diagnosis of Neurasthenia (Shen-Jing Shuai-Ruo 神經衰弱). Upon interview with the Schedule for Affective Disorders and Schizophrenia (presumably a translated version, although th.is was tu1clear}, 87 were diagnosed as having a Major Depressive Disorder (MDD). However, 30% of those MDD patients complained exclusively of somatic symptoms and 70%, although complaining also of psychological distress, predominantly emphasized their somatic symptoms over their psychological ones. Treatment with tricyclic antidepressants led to substantial improvement in twothirds of the MDD patients. Kleinman, therefore, concluded that Major Depression in the Chinese usually present with somatic symptoms rather than mood disturbance.

Kleinman's data, however, raise several questions regarding the nosology of Major Depression {or Anxiety Disorder) in Chinese patients:

(1) Is mood disturbance among the Chinese Major Depression patients absent or denied?
(2) Is Major Depression without mood disturbance still Major Depression or should the syndrome be called Neurasthenia?
(3) Is Major Depression with prominent somatofo1m symptomatology one disorder (i.e., Major Depression) or two (i.e., Major Depression and Somatization Disorder/ Undifferentiated Somatoform Disorder)?

I will now describe a series of 24 Chinese-American patients diagnosed as having Somatization Disorder or Undifferentiated Somatoform Disorder.

METHOD

PATIENTS

Between November 1, 1993, and October 31, 1994, I evaluated a consecutive series of 85 Chinese American patients referred to the Department of Psychiatry, New England Medical Center (NEMC) which is the principal teaching hospital of Tufts University School of Medicine, and to the South Cove Mental Health Clinic (SCMHC) which is a community mental health center. Both NEMC and SCMHC are located in Chinatown, Boston. Seventy-one patients (84.5%) spoke Cantonese, while 13 (15.5%) spoke Mandarin. Several patients, having been born and brought up in this country, also speak fluent English. The patients' age ranged from 15 to 87 years, average was 44.55; 55 patients (64.7%) were female and 30 (35.3%) were male.

DIAGNOSTIC INTERVIEW

The patients were evaluated using the language of their choice. All except three patients were seen for more than four sessions for diagnostic evaluation. While a structured diagnostic interview was not administered, a comprehensive clinical evaluation including a detailed mental status examination was conducted. Areas of uncertainty were repeatedly probed. Some patients were very guarded in the first few sessions, and areas of uncertainty were explored only after rapport had been established.

RESULTS

PROMINENCE OF SOMATIC COMPLAINTS

The chief complaint in 24 (28.6%, 17 females, 7 males) patients was exclusively or predominantly somatic in nature. Somatoform symptoms also occurred in many of the "nonsomatoform" patients, but they were not a predominant part of the clinical picture, and the patients were willing to accept that their disorders were psychiatric in nature. There was no gender difference in the ratio of " somatoform " vs "non- somatoform" patients (X.2=0.45, df=l, NS). The mean age of the "somatoform" and "non-somatoform" patients were not different (45.9±15.7 vs 44.0±18.5, F=.2053, df=83, ns).

All the 24 "somatoform" patients have seen at least 2 other physicians before coming to see us, and all except 3 had consulted traditional Chinese medicine ("herbal") doctors and/or acupuncturists. These patients were convinced that they had a physical disorder and came reluctantly to see a psychiatrist because nothing else seemed to have worked, or else they were told by the other physicians that they had a mental disorder. Clinical features of these patients are summarized in Table 1.

SOMATOFORM DISORDER DIAGNOSIS

Twenty-two patients fulfilled criteria for Undifferentiated Somatoform Disorder (Table 1). One patient fulfilled all c1iteria for Somatization Disorder (#14). She also had Lupus Erythemations, but the immunologist who referred her believed that her somatofo1m complaints were far out of proportion to her Lupus which he thought was in remission. A second patient (#5) also fulfilled crite1ia for Somatization Disorder, but she insisted that she was symptom-free until age 35 when she became a refugee.

All the 24 patients had prominent cardiopulmonary complaints: palpitation, shortness of breath, dizziness, lightheadedness. Fatigue {tiredness, lack of strength} was present in all the patients. Incontrast, pseudoneurological symptoms were uncommon: 5 patients complained of difficulty in swallowing expressed as a sensation of pressure pushing up from the chest that made swallowing food difficult. Vertigo, blu1Ted vision and tinnitus were also common, and might arguably be considered pseudoneurological symptoms, but classical conversion symptoms such as paralysis, convulsions, or blindness was not present in even a single patient.

CONCURRENT PSYCHIATRIC DIAGNOSIS

All except 1 patient had a concurrent Axis I diagnosis: Major Depression in 15, anxiety or panic disorder in 8, and delusional disorder in 1. The 1patient (#4) who did not have a concurrent psychiatric diagnosis complained of sudden onset of severe vertigo after she fell asleep with the cold air of the air-conditioner blowing on her head. Repeated consultation by several neurologists in New York City and Boston failed to yield a neurological diagnosis. The vertigo was so severe that she was bed ridden for 6 months. Acupuncture and Valium (up to 4 mg/day) brought partial relief. She admitted to worrying about her 6-year-old son but denied any other psychiatric symptoms.

After several sessions of psychoeducation, 8 patients (#6, 8, 11, 12, 14, 17, 22) were willing to accept both a diagnosis of a concurrent psychiatric disorder as well as a diagnosis of somatoform disorder (i.e., that their physical complaints could not be explained medically). Another 12 patients (#1, 2, 3, 5, 7, 10, 13, 16, 18, 19, 23, 24), admitted to the presence of psychological distress such as depressed or anxious feelings only after a prolonged period of treatment. Although willing to try psychiatric treatments, they were, nevertheless, reluctant to accept the diagnosis of a concurrent psychiatric disorder or of somatoform disorder. The following 2 cases illustrate these situations:

Patient #20 was working long hours at a restaurant when he
developed bilateral knee pain which was so severe that he could not walk. He saw several orthopedic surgeons and was extensively evaluated, but no diagnosis was made. He subsequently also developed headache, palpitation, short-ness of breath, dizziness, tinnitus and fatigue, and he consulted many traditional Chinese medicine doctors and acupuncturists. He became house bound. His mother (case #] 7) persuaded him to see me, and although he admitted to having severe marital discord, he was much more worried about his somatoform symptoms than his marriage breaking up. Initially he refused treatment, but 6 months later he reluctantly took doxepin which to his surprise made his symptoms much better, and he began vocational training. He then admitted that he had been minimizing his subjective dysphoria. His mother (case # 17) had similar somatoform complaints but also had subjective dysphoria and anxiety. She also improved on doxepin.

Patient #18 exhibited all the symptoms of Major Depression but believed that they were the result of his multiple physical symptoms.
The depressive symptoms improved partially with a tricyclic antipressant, but he found no improvement with his pains. Following an argument with his psychiatrist who explained that his pains were ''psychological, 11 he terminated treatment and discontinued his antidepressants. Nine months later he returned, because he found that his pains were much worse without the antidepressants. Subsequent treatment with doxepin and sertraline resulted in substantial, but not complete, remission of his paints. His depression was in full remission.

Finally, 3 patients (#4, 15, 21) denied the presence of psychological symptoms or remained convinced that the symptoms of sadness or anxiety had occurred only because of their physical symptoms. All patients in this group (#4, 15, 21) refused psychiatric treatment.

RELUCTANCE TO COMMUNICATE SUBJECTIVE DYSPHORIA OR ANXIETY

As already mentioned, many patients initially denied psychological distress or else were convinced that the distress occurred because of the physical symptoms {'Would you not be worried if you had these symptoms?"). Diagnosis of a concurrent psychiatric disorder was based on the overall clinical picture, past history and family history, as illustrated by case vignettes of cases #18 and #20 presented above. The following patient was initially referred to me as a case of anorexia nervosa. The apparent absence of dysphoria was due to reluctance on her part to communicate such feelings:

Patient #16 had two previous episodes in the last 15 years of difficulty in swallowing, bloated feeling in stomach, fatigue, dizziness, palpitation, headache, insomnia, 20-25 lb. weight loss, and amenorrhea. There was no fear of fatness. Both episodes lasted about three years and remitted without treatment. The current episode began 2 years ago and presented with identical symptoms. The referring psychiatrist who also worked at the SCMHC had prescribed lorazepan which the patient took for one year without benefit. I prescribed doxepin which has resulted in a 10-lb. weight gain over 8 weeks; and substantial, but not complete, improvement of all the somatoform symptoms.. The patient has consistently denied any subjective dysphoria to the previous psychiatrist, her individual therapist, and to one of us. There was no family history of a psychiatric disorder.
However, after partial recovery, she disclosed to the social worker, who had been her individual therapist for one year, her sadness over the death of her mother 5 years ago and her worries about her father's lonliness and isolation in China. She could not stop crying during the entire therapy session. When subsequently confronted by one of us about previous denial of sadness, she shrugged her shoulders and said she did not like to talk about feelings.

SOMATOFORM DISORDER IN PATIENTS WITH PHYSICAL DIAGNOSIS

As already mentioned, all the patients had seen at least two physicians in other specialties than psychiatry. Five of them (#6,7,10,13,14) had physical disorders requiring active treatment which could have accounted for some of the somatoform complaints. The referring physician in each case, however, felt that the somatform complaints were out of proportion to the severity of the physical disorder. Very often the possibility of a physical diagnosis was eliminated after a lengthy process of investigations, as the following case illustrates:

Case #24 is a 25-year-old college graduate who began having
depression, anxiety, poor concentration, forgetfulness, insomnia, palpitation, nausea, bloated feeling in stomach, diarrhea and loss of sexual interest at age 20 when he was a sophomore in college. He also developed involuntary choreiform movements involving his limbs, face, head and neck which were suggestive of Huntington's Disease, but there was no family history. Extensive evaluations by several neurologists including repeated MRIs failed to confirm a diagnosis of Huntington's Disease, and there was no evidence of dementia on psychological testing. Family history was positive for Major Depression. Treatment with antidepressants and low-dose haloperidol resulted in substantial improvement, but he dropped out of treatment after 12 weeks. He was subsequently arrested for auto theft and again extensively re-evaluated, but no physical disorder was diagnosed. He refused psychiatric treatment and sought treatment with a traditional Chinese medicine doctor.

DISCUSSION

The findings suggested that somatization among ChineseAmerican patients referred to two psychiatric clinics in Boston occurred most commonly in conjunction with a concurrent psychiatric disorder. Several groups of researchers (e.g., Escobar et al., 1987; Katon et al., 1991; Kirmayer et al., 1993; Simon and VonKorff, 1991; Swartz et al., 1988) found somatization in Caucasian, African-American and Hispanic populations to be accompanied frequently by depression and anxiety. Also in common with the findings in other ethnic groups, we found that full syndrome of Somatization Disorder was rare among Chinese-Americans while a subsyndromal form of the Disorder was much more common. Finally, conversion symptoms such as seizures, blindness, or paralysis were not present in any of our patients. While difficulty in swallowing was present in several of our patients, it was not the chief or predominant complaint. Thus Conversion Disorder appeared to be rare among Chinese Americans. Some investigators (e.g., Tomasson et al., 1991) have suggested that Conversion Disorder should not be linked to Somatization Disorder.

This cohort of Chinese American patients appeared to have a unique somatoform symptom profile. First, cardiopulmonary symptoms such as palpitation, shortness of breath and dizziness were prominent. Second, complaints of vertigo (a sensation that the surroundings were turning around oneself) and blurred vision were prevalent. Finally, fatigue (or weakness or tiredness), usually expressed as lack of strength or power either generalized or confined to the legs, was almost a universal complaint among our patients. In the symptom list for Somatization Disorder, the DSM-IV has not included cardiopulmonary symptoms, vertigo, blurred vision, or fatigue. While our patients may be diagnosed as having an Undifferentiated Somatoform Disorder, the prominence of the cardiovascular complaints, blurred vision, vertigo, and fatigue, indicates a lack of fit or incongruity between their symptom profile and the DSM-N criteria for Undifferentiated Somatoform Disorder.

In contrast, the somatoform symptoms of our patients seemed to fit that of Neurasthenia, a common disorder in the Chinese culture (Kleinman, 1982; Li and Young, 1993; Zheng et al., 1992). The nosology of this disorder continues to be a subject of debate among psychiatrists interested in cross-cultural phenomenology (Lee, 1994; Yan, 1994). 1he DSM-N stated that "Neurasthenia, a syndrome . . . characterized by fatigue and weakness, is classified in DSM-N as Undifferentiated Somatoform Disorder ..." {pg. 451). Lee (1994) has pointed out that in so doing the DSM-N n1ight have committed a "category fallacy". According to the Chinese classification of Mental Disorders, 2nd Edition (CCMD-2, Young, 1989), Neurasthenia or Shen-jing Shuai-ruo should be diagnosed if 3 of the 5 following symptoms had been present for at least 3 months: weakness symptoms, emotional symptoms, excitement symptoms, tension-induced pain, and sleep disturbance. However, Neurasthenia should only be diagnosed after other psychiatric or physical disorders that might "produce" similar symptoms had been excluded. While most, if not all of our patients would fulfill the CCMD-2 criteria for Neurasthenia, it is unclear if the presence of a concurrent psychiatric or physical disorder would exclude a diagnosis of Neurasthenia. More recently, some researchers {e.g., Abbey and Garfinkel, 1991) have suggested that Neurasthenia may be linked to Chronic Fatigue Syndrome. However, none of our patients had lowgrade fever, nonexudative pharyngitis, palpable or tender lymph nodes, n1igratory arthralgias, or acute onset of symptom complex, features deemed essential for the diagnosis of Chronic Fatigue Syndrome (Holmes et al., 1988). I raise these issues to illustrate the difficulty I have in classifying these symptoms according to currently available diagnostic schemes.

Finally, I return to the 3 questions I posed in our Introduction. According to the findings in this preliminary study, mood disturbance in the form of depression or anxiety was, indeed, present and diagnosable in the majority of the Somatform Disorder patients. Most of the patients who initially denied subjective psychological distress later adn1itted to it. I have diagnosed in these patients both a Somatoform Disorder and an additional concurrent psychiatric disorder and left open the issue of whether the somatoform complaints could be entirely subsumed under the concurrent psychiatric disorder; i.e., I am uncertain if Major Depression, Anxiety/Panic Disorder or Delusional Disorder can "produce" these somatoform complaints. I concur with Simon and VonKorff (1991) that somatization could not be viewed as a defense against awareness of emotional distress. The initial absence of psychological distress among our patients appeared not to be related to a lack of awareness but to a reluctance to disclose such distress. From my data, I cannot answer the question of whether Major Depression or Anxiety Disorder without mood disturbance is still Major Depression or Anxiety Disorder, or whether the term Neurasthenia n1ight be more appropriate. Discussions on nosology involve not only data, of which we certainly need more, but also issues such as whether psychiatric diagnostic categories should be user-friendly (Lee, 1994). To our Chinese-American patients, terms such as Somatization Disorder or Undifferentiated Somatoform Disorder sounded weird and alienating and did not resonate with their illness experience. As patients in many Western societies are becoming more multicultural, the need for research into these issues has become urgent.

ISSUES FOR FUTURE RESEARCH

There are two issues that demand urgent attention for researchers interested in cross-cultural phenomenology:

(1) How is the pattern of somatization among Chinese patients different from patients of other ethnic and racial backgrounds? To our knowledge, there has never been a detailed, systematic study comparing somatoform disorders across cultures
(2) In a society that is undergoing rapid socio-cultural change such as Hong Kong, do Chinese patients present with similar somatoform symptoms?

I hope that this pilot study may stimulate more data-based studies.

REFERENCES

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Cloninger, C.R. (1986) Somatoform and dissociative disorders. Chapter 9 in Winoken, G. & Clayton, P_, (eds.) The Medical Basis of Psychiatry. Saunders, Philadelphia.

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L.K. George Hsu MD, Professor of Psychiatry, Department of Psychiatry, Tufts University School of Medicine. New England Medical Center - Box 1007, 750 Washington Street, Boston, MA 02111, USA.