Somatization as a core symptom of melancholic type depression. Evidence from a cross-cultural study

journalof AFFECTIVE DISORDERS Journal

of Affective

Disorders

32 (1994) 253-256

Somatization as a core symptom of melancholic type depression. Evidence from a cross-cultural study Dieter

Ebert

‘,*, Peter Martus

b

a Department of Psychiatry, Unicersity of Erlangen, Erlangen, Germany b Department of Biomedical Statistics, lJniuersi@ of Erlangen, Erlangen, Germany Received

7 March

1994; revised version

received

13 June 1994; accepted

13 June 1994

Abstract The study questions whether different types of somatization may be a core symptom of melancholia, thus, being invariable across cultures and being a candidate for neurobiological research and diagnostic criteria. 51 Turkish patients and 51 education-matched German patients with melancholic depression were compared for two types of somatization. Turkish patients had higher frequencies of somatic preoccupation and hypochondriasis but they were not different in the perception and experience of somatic symptoms. It is concluded that: (1) somatization has to be differentiated psychopathologically; (2) it may be a neurobiological core symptom of melancholia in the well-defined sense of ‘perceiving abnormal somatic symptoms’; and (3) it may be a culture-bound symptom in the sense of ‘being

abnormally concerned with somatic symptoms or hypochondical Keywords:

Depression;

Somatization;

Cross-cultural;

Turkish;

1. Introduction Somatization has been proposed to be one core symptom of the endogenous or melancholic type of depressive disorder (e.g., Akiskal, 1983). It is questioned in this study whether somatic symptoms are essential concomitants of the neurobiological disease process in melancholia or whether they should be better explained psychologically, e.g., as a way of expressing distress. The

* Corresponding

author. Address: Department of Erlangen, Schwabachanlage Germany.

try, University Erlangen,

0165.0327/94/$07.00 0 1994 Elsevier SSDI 0165.0327(94)00063-L?

Science

of Psychia6-10, 91054

fears’.

Melancholia

second interpretation of a non-biological origin of somatization would be strengthened by findings that somatization is more frequent in lower social strata and that frequency and severity appear to vary across ethnic groups within a country and across different cultures with higher rates of somatization in non-western depressed patients, e.g., Turkish samples (e.g., Bdker, 1975; Basoglu, 1984; Kirmayer, 1984; Kleinman and Good, 198.5; Escobar, 1987). However, studies so far have not concentrated on melancholic depression but on depressive syndromes as a whole (this is also the case for the transcultural study of depression by Sartorius et al. (1983)) and can, therefore, not answer the question of this study.

B.V. All rights reserved

Psychopathologically, somatization has at least two aspects which are often used simultaneously. (1) Somatization may mean ‘perception or experience of abnormal somatic symptoms (pain or vegetative symptoms)‘. They need not be a chief complaint or a thought content of depressive suffering nor are they necessarily presented to the physician. (2) Somatization may mean ‘hypochondrical fears or preoccupations with physical health or somatic sensations as a major content of depressive thinking and a chief complaint.’ They are presented to the physician but they need not necessarily be accompanied by the real experience of abnormal somatic symptoms. To investigate whether somatization may be a candidate for a socio-culturally invariable core symptom of melancholic depression prefering a neurobiological interpretation, we compared somatization in Turkish and German patients with melancholic depression with regard to the above-mentioned psychopathological differentiation.

2. Methods 51 (25 women and 26 men) consecutively admitted Turkish inpatients with the diagnosis of Major Depression, melancholic type (DSM-III-R) and 51 sex-matched German inpatients with the same diagnosis were investigated fulfilling the following inclusion criteria: 1 First admittance for a depressive disorder. 2 No organic abnormalities (physical examination, laboratory parameters, X-ray-computed tomography, KG, exclusion of organic etiology of somatic complaints by medical specialists for the relevant physical diseases). 3 No higher school education; at least 6 years but not > 9 years school. 4 Sufficient knowledge of the German language (a bilinguistic speaker participated in the investigation in doubtful cases>. 5 No other axis I diagnosis in DSM-III-R. All Turkish patients were foreign workers in Germany or family members and they had spent their adolescence in Turkey. All patients were investigated with a modified

version of the Diagnostic Interview Schedule (DE; Robins et al., 1981). Severity of depression was assessed by the Hamilton Depression Scale, 21 items. The presence or absence of the following two psychopathological items, which were differentiated in the Introduction, were evaluated: 1 Hypochondriasis and somatic preoccupation (the patients were asked for their chief complaints. The item was positively rated if patients mentioned spontaneously somatic complaints or showed hypochondriasis according to the DIS system). 2 Perception and experience of abnormal somatic symptoms (the patients were explicitely asked for the presence of the 35 symptoms listed in the DSM-III-R criteria for somatization disorder. For a positive rating of the item, at least four positive symptoms of the list had to be present). The two groups were compared with bivariate statistics (x’ and t tests) and with a multivariate hiloglinear model (SPSS, version 4.0.1) with the parameters nationality, sex, somatic preoccupation, perception of somatic symptoms. The loglinear model takes into account that the psychopathological items are probably not independent and that sex impact may be different between cultures.

3. Results The two groups did not differ in education, sex distribution, age (Turkish: median 39 years; German: median 40 years) and severity of depression (Turkish: Hamilton Score 27.7 f 3.2; German: 27.2 f 3.0). Only somatic preoccupation and hypochondriasis but not the perception of abnormal somatic symptoms were significantly different between the two groups as well in the bivariate as in the multivariate statistics (Tables 1,2). The two groups did not differ in the frequency of the single somatic symptoms of the symptom list of somatization disorder (DSM-III-R) but headache was more frequent in the German group (Table 11. Higher frequencies of somatic preoccupation in

of Affrctic,e Disorders S2 (1994) 253-256

D. Ebert, P. Martus /Joumul

the Turkish sample were due to differences in hypochondriasis in a strict sense and preoccupation with somatic symptoms other than pain. Table 2 lists all interactions (partial associations) of the four-way loglinear model with P < 0.1. The shown interactions had to be interpretated as follows after calculating the estimates for parameters and cross-tabs for the items: Somatic preoccupation and hypochondriasis are significantly more frequent in the Turkish sample (independently of the item ‘perception of somatic symptoms’ with a significant two-way interaction but no significant three-way interaction). Perception of somatic symptoms shows a trend to be more frequent in women (independently of nationality). Perception of symptoms and preoccupation with it are significantly correlated. This is especially the case for women (three-way interaction

Table 2 All partial associations nationality/sex/perception preoccupation

255

with of

P < 0.1 of hiloglinear model: somatic symptoms/somatic

Interactions

P<

Sex/perception of somatic symptoms/ somatic preoccupation Sex/perception of somatic symptoms Nationality/somatic preoccupation Perception of somatic symptoms/ somatic preoccupation

0.047

All other

interactions

were not significantly

0.075 0.000 0.003

associated

of these three symptoms P < 0.047, no interaction with nationality). There were no significant age differences between those patients having symptoms and those not having symptoms (t tests).

4. Discussion Table 1 Psychopathology of somatization in Turkish and German tients with Major Depression, melancholic type

Perception/experience of somatic symptoms Symptoms Gastrointestinal symptoms Pain including headache Cardiopulmonal symptoms Pseudoneurological symptoms Psychosexual symptoms Hypochondriasis/somatic preoccupation Preoccupation with pain other symptoms Hypochondriasis

pa-

Turkish

German

group (n=Sl) n (96)

group (n=51) n (55)

43 (84.3)

44 (X6.3)

22 (43.1) 43 (84.3) 25 (49.0) * 39 (76.5) 18 (35.3) 43 (84.3) 42 (X2.3) *

20 (39.2) 39 (76.5) 35 (68.6) * 43 (X4.3) 12 (23.5) 44 (86.3) 22 (43. I) *

25 (49.0) 39 (76.5) * 20 (39.2) *

22 (43.1) 12 (23.5) * h(ll.8)*

* P < 0.05 x’ test Turkish vs. German sample. Single symptoms of category ‘perception of symptoms’ were assessed according to list of symptoms in DSM-III-R somatization disorder (35 symptoms in five categories) and are listed according to five categories in DSM-III-R. Four symptoms had to be present for assessment of general item ‘perception of symptoms’. Items of ‘somatic preoccupation and hypochondriasis’ are explained in Method section.

The study questions whether the different types of somatization may be a core symptom of melancholia, thus, being invariable across cultures and being a candidate for neurobiological research and diagnostic criteria. The data cannot be generalized at all and they do not allow conclusions concerning depression or somatization in general. Therefore, comparisons with previous cross-cultural research does not seem appropriate. Compared with a German sample Turkish patients with melancholic depression were more frequently preoccupied with somatic complaints. From our data, this cannot be explained by different education or socio-economic status or by different culture-bound sex behaviour. It does not seem to be an effect of different perceptions of abnormal body sensations or of higher frequencies of somatic symptoms. This finding is consistent with the well-known theories that there is a higher tendency in some cultures and some socio-economic strata to use external referents for emotional expression rather than internal psychological referents (Marsella et al., 1973) or to chose different linguistic representations for the expression of undifferentiated emotional states

256

D. Ehert, P. Murtus /Journul of Affective Disorders 32 (1994) 253-256

(Leff, 197.3). Therefore, it should be concluded that ‘somatization as having hypochondrical fears and complaining of somatic symptoms’ is not a candidate for a neurobiolological melancholic core feature but, instead, it is consistent with a culture-bound symptom. On the other side, the pure existence and perception of abnormal body sensations or pain in melancholia cannot be substantiated to be a function of cross-cultural differences. Therefore, a second psychopathological assessment of somatization, i.e., ‘somatization as experiencing pain and vegetative disturbances’ may, indeed, be a core feature of a (endogenous or melancholic) subtype of depression. This view is supported by the high frequency of these somatic sensations ( - 80%) in our study in both groups. In conclusion, it is proposed that somatization should be differentiated psychopathologically in a disturbance of depressive thought content and a disturbance of body perception or experience. The first is more likely to be a cultural phenomenon, the second is more likely to be independent of these influences. Instead, it could be substantiated as a core feature of the endogenous

or melancholic disease process and be implicated as a target of neurobiological research. Akiskal, H.S. (1983) Dysthymic disorder: psychopathology of proposed chronic depressive subtypes. Am. J. Psychiatry 140,11-20. Basoglu, M. (1984) Symptomatology of depressive disorder in Turkey. J. Affect. Disord. 6, 317-330. Bilker, W. (1975) Psychiatric der Gastarbeiter. In: Kisker (Ed.), Psychiatric der Gegenwart, Band III. Springer, Berlin, Germany, pp. 429-466. Escobar, J.I. (1987) Cross-cultural aspects of the somatization trait. Hosp. Community Psychiatry 38, 174-180. Kirmayer, L.J. (1984) Culture. affect, and somatization. Transcult. Psychiatry Res. Rev. 21, 159-188 and 237-262. Kleinman. A.M. and Good, 8. (1985) Culture and Depression. University of California Press, Berkeley, CA. Leff. J.P. (1973) Culture and the differentiation of emotional states. Br. J. Psychiatry 123, 299-306. Marsella, A.J., Kinzie, D. and Gordon, P. (1973) Ethnic variations in the expression of depression. J. Cross-Cult. Psychol. 4, 435-457. Robins, L.N., Helzer, J.E., C’roughan, J. et al. (1981) National Institute of Mental Health Diagnostic Interview Schedule. Arch. Gen. Psychiatry 38, 3X1-389. Sartorius, N.. Davidian, H., Emberg, G., Fenton, F., Fujii, I., Gastpar. M., Gulbinaz, W., Jablensky, A., Kielholz. P.. Lehmann, H., Shimizu, M. and Takahashi, R. (1983) Depressive Disorders in Different Cultures. WHO, Geneva, Switzerland.