Cultural Variables Affecting Somatic Complaints and Depression

Cultural Variables Affecting Somatic Complaints and Depression MARVIN K. OPLER, PH.D., and S. MouCHLY SMALL, M.D.

• Current studies of depression, somatic complaints and suicide emphasize sociocultural concepts. The present paper will deal with the varying prevalence of depression and suicide cross-culturally; and it will, in addition, explore the factors of age and sex, marital status, and class or ethnic group in the studies dealing with the United States. Additionally, any discussion of symptom complexes must take cognizance of the changing nature of the predominant psychopathology and symptomatology in any society through time. The obvious decrease in dramatic, hysterical conversion phmomena as described by Charcot before the turn of the century is a case in point. The greater frequency of anxiety reactions and apparent decrease in hysterical symptoms in American soldiers in the Second World War as contrasted with the First World War similarly highlight the importance of the temporal parameter. :"aturally prevalence studies will tend to vary with the nature of the instrument used to determine the presl'nce of an illness and the personal and social characteristics of the personnel doing the clinical assessment. SUICIDE

Most of the important literature here reviewed is relatively recent (for example Paul Friedman's discussions of the Vienna Psychoanalvtic Society of 1910, called On Silicide [With Partinllor Reference to Suicide Dr. Oplcr is Professor of Social Psychiatry, State University of New York at Buffalo, Buffalo, New York. Dr. Small is Professor of Psychiatry and Chainnan. Bertha and Henry C. Buswell Fellow, Department of Psychiatry-School of Medicine, State University of New York at Buffalo, Buffalo, New York. Presentpd at the Annual \Ieetin!! of the New York Statt' Medical Society, New York City, February 14, 1968, as part of a Symposium on Depression.

among Young Students]') 1 It is fascinating to read Freud's commentary in this volume. He linked suicide with what he called affective processes in melancholia, but he warned his colleagues that the psychoanalytic world of 1910 still lacked adequate means of approaching both the phenomena of depression and of suicide, how it becomes possible for the extraordinarily powerful life instinct to be overcome. Not until the publication of Mourning and Melancholia 2 in 1917 did he relinquish this cautious position, explaining suicide with the formulation of the ego's sadism and murderous impulses against others being turned back upon itself (more specifically upon the introjected, ambivalent love object that became part of the ego). These meetings of the Society in 1910 took place at a time when suicide of youth and adolescents was occurring in Germany and Austria in strikingly large numbers. 'We can note that even today Germany and Austria, along with Japan, are recognized as outstanding "high-rate" countries in suicide epidemiology. Several of those commenting on such high rates noted psychosexual crises and homosexual or identity conflicts for these vouths. Rudolf Reitler presented his idea of ~mgratified libido as fundamental. Wilhelm Stekel added that self destruction represented a wish to kill another or at least to see the target of aggression succumb. Thus, hostility turned inward and the second factor of uncontrolled impulse received attention. But because of limitations in knowledge of cross-cultural factors. no one in 1910 could intercompare the high prevalence rate of suicide with the high rate, for example, in Japan. Had such sociocultural information been available then as it is now, anthropologists would have been quick to point out that intergenerational conflicts in all three of these culhlral

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situations were exacerbated. Even today they continue to be intensified by a rigid hierarchy in social structure which extends into the family scene and imposes insistent demands upon children and youth as to their obligations toward elders and particularly the father as the authority figure. This is not to say that intensifications of duties and obligations in an hierarchical order cannot be found in families of other cultural background on occasion. But statistically, there is more of this combination of hierarchical order and central authority in til(> examplt·s just given. It is important to note that the ehildhood eonfliets may be intensified or exacerbated during adolescence bv other social phenomena. Both in \Vest G'ermanv and in Austria even today, young people dl; not typically continue education during adolescence as in our culture. Instead, in the early teens, they are apprenticed in joh situations where orderly hierarchical demands are again continued. For childrm often reared in the tradition of obedience and duty, the impact of authoritarian models must be intensified by continuity and repetition.

If one looks within a national framework for other "high-rate" suicide' conditions, the American Indians in the United States represent an outstanding example from tribe to tribe, or from reservation to reservation. Here, of course, one cannot refer the high-rate of both adult and youth suicide to a hierarchical and authoritarian social structure as such. These Indian cultures vary considerably and typically class or authority features are often absent. But reference to orderly hierarchy is not our central point taken alone. It is important, no doubt, in those sihmtions where it intensifies or exacerbates intergenerational conflict. As a matter of fact, the telling significance of the American Indian situation is the resulting factor of intergenerational conflict. Among them this is largely a values conflict between the older disappearing culture and the American ethos. The older Indian has been caught up in this intergenerational conflict wherever \Vhite culture encroaches and causes rapid breakdown. The Indian youth, whose predicament may be gauged by exceedingly high suicide figures is also enme'shed increasingly in the same circumstances; and his epidemiological rate262

increases reflect this. Such factors as hierarchical social order or authoritarian family system in the German and Japanese cases leading to intergencrational conflict are of course sociocultural. Freud observed that anger toward a love ohject could be turned back by the individual upon himself. This concept of suicide as a type of inverted murder was revived recently by lIerbert Hendin in his article on the psychodynamics of suicide." To match these factors with sociocultural ones, Hendin attempted to prove in a subsequent book; that two countries in this are'a, Denmark and Sweden, had high rates. He was answered immediately by J. Block and B. Christiansen' who tested the hypotheses and found them both inconsistent and wanting. These authors, however, investigated the background factors of childrearing practices in families of college educated parents. \Ve are not implying here that the factors of child-rearing practices themselves are unimportant, but one of the authors of this paper (M.K.O.) in making surveys in both these countries found that Scandinavian experts, such as psychiatrists and psychologists, disagreed markedly with Hendin in his particular descriptions of these practices. One psychiatrist in Stockholm, Dr. Ruth Ettlinger,'; was among those strongly disagreeing along with her psychiatric colleagues at Sodersjukhuset, Sweden's largest hospital in Stockholm, both with the discourses of child-rearing practices and the allegations of high rates. Similarly, various experts in Denmark disagreed with the Hendin analysis, such as Dr. Jonna Wiltrup and her colleages in clinical psychology at the Montebello Day and Night Hospital in Copenhagen. It suffices to mention in passing that a Scandinavian country like Sweden is far down in the World Health Organization suicide list, number 11 in fact, and that Denmark also is far behind the above mentioned countries of Austria, \Vest Germany and Japan in such rates. Furthermore, Denmark's population of between 4 and 5 million and Sweden's of only 7 million, keep unusually good records of both suicides and attempted suicides in contrast to very many other countries on the list whose records probably minimize this phenomenon. It would appear that scholars in the United States have for some time been focusing upon both Volume IX

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questionable data and possibly upon erroneous analyses of Scandinavian data to seek clues for cross-cultural insights into variations in suicide rate. One wdl-informed commentator, Dr. Erwin Stengel, in his book, Suicide (/1/([ Attempted Suicide,7 apparently amused by the American fashion for pointing a finger at Sweden, noted that it was President Eisenhower himself who singled out the Swedish rate as a dire warning of what happens to a country with a good deal of social plannin~. Stengel remarks that our ex-President "must have been unacquainted with" the much hi~ll­ er suicide rates of other places like Allstria, \ \'est Germany (\\'est Berlin), Japan and even Switzerland whose political complexion in the 1960's was possibly more to his liking. DEPRESSIVE STATES

Of course, suicide is not a disease entit\· in itself, but represents a symptom in some" depressive states. If, then, we look at concepts of depression, we find that these have also changed in the course of history. R. Crinker and his colleagues J. ~1i1ler, ~f. Sahshin, H. Nunn, and J. Nunnally in their book, The Plle1I01111'IUl of Depressions' were shocked at the inadequacy of information in hospital charts dealing with depression and remarked that these omit demographic and social data. In more socially oriented studies such as the Midtown Manhattan Mental Health Research Study," 24 percent of the :'\ew York poplllation under investigation showed some notable symptomatolo/:,'Y of depressive states. This study included treated prevalence but added to it the data on a random sample of persons in the gl'neral community. To comment again on Scandinavia, two psychiatric epidemiologists, A. Sorensen and E. Stromgren,IO have estimated a much lower frequency of depressive states (only 4%) from parts of Scandinavia. H. Ripley," in 1947, made a survey of patients seen by psychiatric consultants in the New York Hospital and found as many as 28 percent depressed, a figure which relates well to that of the Midtown Study. AGE

More recently, F. Redlich and D. Freedman 12 emphasized that depressions occur in all age groups in the U.S. and are not "infrequent in young adults." Louis Dublin '3

S~1ALL

in his classic study shows that the Census of 1959 reflects an increase of terminal suicides with age (although younger people are increasingly suicidal). But as we could also note for the Midtown data, the risk of mental health impainnents in general increases with age simply because untreated illnesses tend to deteriorate or get worse, by and large, with the passage of time. It is well known today that college age youth are the nation's highest potential suicide risk; and that suicide ranks next to cancer and auto accidents as their third greatest health hazard. J. Grofe, 1 I in a college study, supports this contention. In fact, most of the newer studies of depressive states have been age-specific, just as older studies once dwelled on the depression in the senium. J. Sandler and W. Joffe, I:. for example have elaborated upon tIlt' topic of childhood depression recently. E. Deykin and colleagues'" have described the "empty nest syndrome" for middle-aged women where the departure of children has heen the equivalent of a loss of restitutive love objects in lives that lack other satisfaction. Commenting upon these new age-specific studies which tend to group the social and psychological conditions of an age group in society, one could add that the earlier studies of depression in the elderly may well have failed to distinguish psychosocial depressions from physical depletions connected with a senile cleterioration. SEX

Turning to the factor of sex, we all know that more women are involved in attempted suicides than are men, hut that paradoxically more men have terminal suicides than do females. In addition, for some time reactive depressions have been regarded as occurring earlier for women in our society, either prior to or concurrent with the menopause. It therefore appears, to follow the French sociologist, Emile Durkheim, that women's social status and role in our society is all the more vulnerable to psychological disturbance of this sort because of their lesser involvement in the larger concerns and activities of the culture. This, perhaps, reflects in their more histrionic suicide attempts, reactive depressions prior to or during menopause, and also what E. Deykin calls the "empty nest syndrome." Men, on the other hand, confronted more with the earnest problems of society tend to

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show, as in the Midtown data, both greater mental health impairments in general and also more violent techniques of actual suicide leading irreparably to actual death. However, psychiatric studies in the United States have for long claimed that more women than men suffer from depressive state disorders. L. Taylor and S. Chave,17 in their book, Mental Health and Environment find neurotic depressions much more common in British females than in males. Corroborating the British and American findings, Sorensen and Stromgren "' find the prevalence in Scandinavia much higher for women. I\ACE

One of the most fascinating aspects of the epidemiology of depressive states is the low prevalence of depressives among l\'egrocs in the United States particularly in the South. In Baltimore, the famous team of P. Lemkau, C. Tietze and M. Cooper" reported as long ago as 1942 that Southern :\egroes in particular had low rates. In the International Journal at Social Psychiatry, A. Prange,I" twenty years later, reported on the cultural aspects of these low rates. According to this study, Southern Negros not only had a great deal of sustained culhlral deprivation with which to contend, so that they were quite used to losses of all sorts, but even more significantly they had strong ingroup solidarity to bolster them emotionally in the face of special deprivations such as death, separation and the like. \Ve should add to this that the Southern l':egro also has shown greater vitality in the enactment of aggrieved feelings within his own group; his spirituals and expressive religious ceremonies symbolize quite well the group ethos of expressing the obviously strong feelings against rejection and deprivation in all of its forms. Thus, spirituals, church services, burial societies for some time have been an outlet for the natural feelings of hopelessness and despair. It is instructive to compare such trends in l\'e~ro society with the general drift of poorer Puerto Ricans to similar cultural forms emphasizing local (barriolike) solidarity and Pentecostal and storefront forms of church organization. The Negro today, unlike those of former generations, has reacted to continuing rejection with greater direct ventilation of aggressive feelings. 264

MARITAL STATUS

Turning to the factor of marital status, all studies of mental illness epidemiology, whether in Midtown Manhattan or in New Haven, generally agree that mental disorder occurs more frequently in the unmarried. Most argue that a modicum of mental health aids in achieving and holding to a marital relationship. In Midtown, for example, both the unmarried and divorced male had higher rates of serious psychopathologic impairment than the married male. Also in the Midtown studies of schizophrenics conducted by Opler and Singer,2:1 the male schizophrenic patients were often unmarried or divorced. But even in the schizophrenias, differences occurred in this factor for such groups as the ItalianAmerican or the Irish-American, with the latter (the Irish) showing more unmarried schizophrenics. The Italian schizophrenic, on the other hand, showed more marital attempts. They also showed evidence of more affective coloring in their illnesses which were ultimately diagnosed as schizo-affective disorders in contrast to the Irish schizophrenics with paranoid reactions. These results accord well with information on depressive states, which unlike schizophrenia occurs more frequently in those who are married. Depressed patients, unlike schizophrenics, more frequently succeed in effecting marriage. In fact, Briggs in studies of hospitalized female depressed neurotics, found that more were married than in the general control group female population. Whether this reflects the problems of the female role in our society, more than the marital status, requires further shldy. CLASS A:-;D ETIINIClTY

However, the class factor, like that of ethnicity, is somewhat clearer in current studies of the depressive states. The New Haven shldy of Hollingshead and Redlich found neurotic depression twice as high in upper social classes as in the lower class but it also found that psychotic depressions were more than twice (2J2) the amount in the lower class. In Midtown Manhattan, we found three times as many depressions in the lower class than in the upper, and our slight expansion of the New Haven rate is no doubt connected with Volume IX

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the fact that we added random community samples to a treated prevalence rate. All of this tends to correct the earlier classical findings of Faris and Dunham"tI which associated depressive states with high status. However we must remember, at the same time, that such low status ethnic groups as the Southern Negro may escape these hazards by reason of sociocultmal forms for ventilating the sense of being aggrieved. No doubt what Erich Lindemann has called the necessity of "griefwork" in the bereavement process on an individual plane is paralleled on the social level by group expressive fonns which symbolize thc same sense of grid and loss. J. J. Schwab and co-workers"' studied depressivp fl'actions of medical inpatients in a genera I hospital, specifically excluding thosc dia~nos('d as manic-depressives. Each patient was ('valuated bv fom measures which included a dia~nosis by the medical staff. The latl('r tended to note depression in upper class patients and wcre prone to ignore such reactions in lower class patients. Similarly they found that characteristic symptoms varied with social class. SO~[ATIC CO~[PLAI:\TS

Certain of the relationships between sociocultural factors and depressive states are also highlighted by the studies which have been made on somatic complaints. In the classical Boston area studv of ~1. Zborowskj22 on ethnic variations in re~ponse to pain, the ItalianAmerican sample showed a greater sense of immediate pain awareness than the Irish one which tpnded to repress such feelings. In the same study, the American-Jewish sample (especially the first generation) had a future time orientation in regard to pain or even hospitalization, being more concerned about the consequences or ultimate survival in the illnesses in question. The Opler and Singer2 " studies of Irish and Italian schizophrenics again found hypochondriacal complaints high among the Italians, but extremely low in the Irish. No doubt, two sets of factors, namely the strength or weakness in what Paul Schilder called "body image," on which S. Fisher and S. Cleveland"' have recently elaborated, and the second factor of ethnic group definition of psychosocial roles for particular sex groups converge to give a cultural definition of illness. September-October 1968

In addition, clinical observations would support the idea of different class, as well as ethnic definitions of depression itself. In the lower class, mental illness is seen more often as the affective symptoms themselves, or sometimes, as with lower class PUNto Ricans as purely organic disorders. We may add here, in respect to somatic complaints in most urban groups, females tend to somatize their difficulties, while males refer these to such matters as inability to cope with life situations. The model wc have most used in psychiatry for typical psychological symptoms of depression is somewhat different from the lowerclass model and has tended to stress the Protestant ethic of guilt, or a sense of alienation and separation with clearly more psychological and philosophically rationalized symptoms. The upper class cases may ha\'(' ('ven a still more sophisticated or psychological quality including in the well-educated patient deep dissatisfaction and even horedom with the tenor of social life. Also we believe that this somewhat variable diagnosis of depression Illay he disguised by the social class factor, and that upper class persons, for example, may hath experience and also he able to express their Sense of psychological malaise more than the lower for the same reasons rooted in education and typical experience. Middle and upper class patients, in psychotherapy, not only receive less organic treatments, but also themselves consider this as inferior to psychological forms of therapy. Finally, Small and Regan 2a have recently published upon the importance of short-tenn and supportive modes of treatment of various kinds which may be utilized in brief psychotherapy of depressive states. The incisiveness and ultimate worth of these techniques will prohably rest increasingly upon our knowledge of the various kinds of depressed patients we encounter in community psychiatry now and in the future. In such programs, the ethnic and class variahles, and the age and sex differentiations we have noted above will prove helpful. REFERENCES I. Friedman, P.: On Suicide (With Particular Reference to Suicide among Young Students), New York, International Universities Press, 1967. 265

PSYCHOSOMATICS 2. Freud, S.: Mourning and ~leIancholia, in Strachey, J., Ed.: The Standard Edition of the Complete Psychological Works of Sigmund Freud, London, Hogarth Press, 14:239, 1957. 3. Hendin, H.: The Psychodynamics of Suicide, }. Nero. Ment. Dis., 136:236,1963. 4. Hendin, H.: Suicide and Scandinavia, New York, Gnme and Stratton, 1964. 5. Block, J. and Christiansen, B.: A Test of Hendin's Hypotheses Relating Suicide in Scandinavia to Child-Rearing Orientation, Scand. ]. PsycllOl., 7:267, 1966. 6. Ettlinger, R.: Suicides in a Group of Patients Who had Previously Attempted Suicide, Acta Psychiat. Scand., 40:363, 1964. 7. Stengel, E.: Suicide and Attempted Suicide, Baltimore, Penguin Books, 1964. 8. Grinker, n., et al.: The Phenomena of Depressions, ;'\Jew York, HoebN, 1961. 9. Srole, L., Langner, T., ~lichad, S., Opler, ~1. K., and Rennie, T. A. c.: ~lental Health in the Metropolis: The ~lidtown \Ianhattan Study, :-.lew York, ~IcGraw-HilI, 1962. 10. Sorensen, S., and Stromgren, E.: Frelluency of Depressive States Within Geographical y Delimited Population Groups, Acta Psychiat. Scand. Suppl., 162, 37:62, 1961. 11. Ripley, H.: Depressive reactions in a General Hospital, ]. Nerv. Ment. Dis., 195:607, 1947. 12. Redlich, F. C. and Freedman, D. X.: The Theory and Practice of Psychiatry, New York, Basic Books, Inc.. 1966, p. 533. 13. Dublin, L. I.: Suicide: A Sociological and Statistical Study, :-.lew York, The Ronald PH'SS Co., 1963. 14. Grofe, J.: Depression in College Students, ]. Anwr. Col/. flealth Ass., II: H)7, Fehruary, 1963.

15. Sandler, J. and Joffe, W. G.: Notes on Childhood Depression, Int. ]. Psychoanal., 46:88, 1965. 16. Deykin, E. Y., et aI.: The Empty Nest: Psychosocial Aspects of Conflict Between Depressed Women and Their Grown Children, Amer. ]. Psychiat., 122: (12), 1422, June, 1966. 17. Taylor, L. and Chave, S.: Mental Health and Environment, London, Longmans, 1964. 18. Lemkau, P., C. Tietze, and Cooper, M.: ~fental Hygiene Problems in an Urban District, Ment. Hyg., 26: 100, 1942. 19. Prange, A. J. and Vitols, \1. \1.: Cultural Aspects of the Relatively Low Incidence of Depression in Southern Negroes, Int. ]. Soc. Psychiat., 8: 104, Spring, 1962. 20. Faris, R. and Dunham, H.: Mental Disorders in Urban Areas, Chicago, University of Chicago Press, 1939. 21. Schwab, J. J., et al.: Sociocultural Aspects of Depression in Medical Inpatients, Arch. Gen. psychiat., 17:533-538,539-543, November, 1967. 22. Zborowski, M.: Cultural Components in Response to Pain, ]. Soc. Issues, 8: 16, 1952. 23. Opler, M. K. and Singer, J. L.: Ethnic Differences in Behavior and Psychopathology, Int. ]. Soc. Psychiat., 2:11, Summer, 1956. 24. Fisher, S. and Cleveland, S.: Body Image and Personality, Princeton, New Jersey, Van Nostrand, 1958. 25. Regan, P. F. amI Small, S. \1.: Brief Psychotherapy of Depression, in Curro PSljchiat. Ther., 1966, New York, Grone and Stratton, Inc., 1966. 2211 Main Street Buffalo, New York 14214

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