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Culture and somatization
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Symposium abstracts / Journal of Psychosomatic Research 55 (2003) 111–129
most recent phase has completed testing in over 60 practices as part of the RESPECT-Depression Project. Evaluation focuses on 6-month patient outcomes and the nature of the process of care. With the availability of successful clinical models, the primary challenges in the next phase are developing effective methods to disseminate and sustain these models of care. The dissemination strategy provides training as well as implementation strategies and tools to the quality improvement infrastructures of the partner health care organizations. Evaluation data is drawn from organizational administrative sources, participant surveys, direct observation of organizational decision making and dissemination processes, and key informant interviews.
Psychiatry and bioethics (Chair) Steinberg MD, Bostwick JM, Chen DT, Lederberg MS, Surman OS, (Discussant) Cohen MA Bioethical issues are a particularly intriguing and challenging aspect of the psychiatrists’ clinical work in the general hospital. C-L Psychiatry has historically been long involved in many of these issues, such as informed consent, truth telling and refusal of treatment, to the more recent ethical problems in end of life care, organ transplantation and others. C-L psychiatrists involvement in bioethics in the United States has ranged from psychiatric or bioethics consultant, ethics committee member or chair, to prominent roles in major ethics organizations, and journals. This symposium will provide a broad overview of psychiatry and bioethics. It will address the role of the psychiatrist as bioethics consultant, some of the most important areas of bioethical concern for the C-L psychiatrist, and consider how to train psychiatrists for their role in bioethics The speakers and discussant have all had extensive experience as C-L psychiatrists working in bioethics in major academic centers in the United States, and have made important contributions to the rapidly growing literature on psychiatric aspects of ethics.
The psychiatrist as bioethic consultant Lederberg MS Stressful situations often precipitate dysfunctional responses ranging from mild stress reactions to psychiatric decompensation in vulnerable individuals. The more complex the scenario, the more likely it will have an ethical dimension. Psychiatrists can bring a unique understanding of the nonrational factors that impinge on all human activities. But they need a precise awareness of the difference between exercising their clinical expertise and facilitating ethical decision-making. This paper outlines a schema for recognizing that distinction and illustrates ‘‘pseudoethics’’, ‘‘pseudo-psychiatry’’ and ‘‘psychiatry/ethics’’ consultations. It describes how to make a ‘‘situational diagnosis’’ that teases out (1) patient/families issues, (2) medical staff issues, (3)staff/patient interface issues, (4) legalregulatory issues and (5) ethical issues. This enables the psychiatrist to institute an appropriate ‘‘hierarchy of interventions’’: (a)educational, (b)psychological and (c)ethical. These will be described, along with a method of analyzing the ethical issues that emerge clearly once the situational diagnosis is completed.
Informed consent and live donor selection in organ transplantation Surman OS, Fukunishi I, Allen T, Findley J Organ donation from living donors was a source of ethical and psychological debate in the inchoate progress of kidney transplantation during the 1960s. Subsequent progress in transplantation biology, shortage of available cadaveric organs, rise in consumerism and decline in medical paternalism led been associated with increased acceptance of live donor participation. Has the pendulum swung too far? The inherent limitations
of informed consent and an excessive emphasis on autonomy/rights in donor selection are of great concern now that donors are being exposed to increased perioperative risk. We explore these considerations as they pertain to live donor partial right lobe transplantation.
Psychiatry and bioethics Chen DT, Rosenstein DL, Miller FG As other panel speakers have discussed, the practice of psychiatry in the general hospital setting is infused with bioethical issues. As Psychosomatic Medicine moves toward subspecialty status in the United States, issues of training psychiatrists for their role in identifying, managing, and resolving bioethical issues embedded in the practice of psychiatry in general hospitals will receive more formal attention than it does currently. Dr. Donna Chen recently completed formal postgraduate fellowship training in ‘‘Bioethics and Consultation – Liaison Psychiatry’’ cosponsored by the Psychiatry Consultation – Liaison Service, National Institute of Mental Health and the Department of Clinical Bioethics, National Institutes of Health — the first such formal training experience in the United States. From this perspective, she will discuss ways to incorporate bioethical content and processes into training for psychiatrists who serve as consultants in general medical and surgical settings. She will also discuss potentially new roles for psychiatrists in clinical research ethics activities.
Psychiatry and bioethics Bostwick JM When key terms lack definition, ethical discussion is obfuscated. In the medical arena, suicide is one such term in which overgeneralizations in the literature include several distinct entities under one blurry rubric. In a widely cited 1971 American Journal of Psychiatry article, Abram et al. declared that 5% of dialysis patients die by suicide. Subsumed in their definition of suicide were deaths by treatment noncompliance, treatment refusal, and treatment withdrawal. This presentation will offer a new taxonomy based on classifying self-destructive deaths according to two parameters: (1) whether the deceased intended death, and (2) whether others collaborated in the decision. As attitudes toward end-of-life options and decision making have evolved in the three decades since the Abram article, treatment withdrawal has become commonplace. Physician-assisted suicide and euthanasia are practiced in certain jurisdictions and hotly debated in others. The field of suicidology wrestles with distinctions between suicide and parasuicide, potentially life-threatening behavior for another purpose than ending life. With all these entities labeled suicide, the term fails to have either specificity or relevance. This taxonomy is offered in hopes of clarifying the nature of self-induced death in medical situations so that ethical discourse can better grapple with social and psychological complexities in life-ending acts.
Culture and somatization (Chair) Koh KB, (Presenters) Mak WWS, Kim HW, Hsu GLK, Koh KB, (Discussant) Tseng W Somatization is a universal psychopathology. Recent discussions of somatization have generally occurred on a descriptive and individual psychological level, but cultural factors are rarely discussed. Pattern of symptoms and its cultural factors in the conversion of emotional distress to the somatization are much different from culture to culture. The conventional impression that somatization is prevalent in the non-Western or traditional society and that it is due to poor differentiation of the psyche is seriously criticized. Cultural metaphors of expressing emotional pain, traditional disease concepts, conventional way of adopting a given culture and society, medical delivery
Symposium abstracts / Journal of Psychosomatic Research 55 (2003) 111–129 system, and milieu could be regarded as important cultural factors of somatization. In this symposium, we are going to review and discuss 4 subtitles: Somatization in the Chinese Diaspora, Korean Culture and Somatization, Western Culture and Somatization, and Anger and Somatization.
Anger and somatization Koh KB Repressed hostility and anger has been described as crucial factors in somatization. Hwa-byung is known to be an anger syndrome specific to Korean culture that is characterized by anger suppression resulting in specific somatization. In this study, the relationship between anger expression and somatic symptoms in each group of depressive disorders, anxiety disorders, somatoform disorders, and psychosomatic disorders was examined. The subjects included patients with depressive disorders, patients with anxiety disorders, patients with somatoform disorders, patients with psychosomatic disorders, and normal controls. The Anger Expression Scale was used to assess the anger expression or suppression. The Somatization Rating Scale was used to assess the level of somatic symptoms. The severity of depression, anxiety, and somatization were assessed using the SCL-90-R. Within the depressive disorder group, the severity of somatization more strongly correlated with the anger-out score compared to the anger-in score, whereas, in the somatoform disorder, anxiety disorder, and psychosomatic disorder groups, the severity of somatization significantly correlated with the anger-in score. These results suggest that anger expression is likely to be predominantly associated with somatization in depressive disorder patients, whereas anger suppression is likely to be associated with somatization in anxiety disorder, somatoform disorder, and psychosomatic disorder patients.
Culture and somatization Mak WW, Cheung FM Somatization is a form of contextualized response to emotional responses that is common among Chinese populations. Based on results from the normative sample of the Chinese Personality Assessment Inventory (CPAI) in Mainland China and Hong Kong (N = 2444) somatization showed a strong interpersonal disposition, with the highest loadings from the Dependability and Interpersonal Relatedness factors. In the restandardization normative sample (N = 1911), almost all of the personality scales of the CPAI-2 were significantly correlated with somatization. These results pointed to the importance of indigenous personality traits in the manifestation of psychopathology. Acculturation can moderate Chinese Americans’ somatization tendencies as they increasingly adopt American illness behaviors. Using data from the Chinese American Psychiatric Epidemiologic Study (CAPES) (N = 1747) it was found that length of residence in the United States and acculturation were not related to somatization. Somatization was significantly influenced by individuals’ level of depression and anxiety, gender, age, education, stress, and instrumental support. Thus, it might be a stress response to heightened distress severity and psychosocial stressors rather than a cultural response to express psychological problems in somatic terms. Our recent studies highlighted significant proximal factors in the explanation of somatization tendencies among the Chinese diaspora.
Somatization in the West Hsu LG By definition, somatoform disorders are presentations of bodily symptoms which have no demonstrable physical origins. Recent discussions of these disorders have generally occurred on a descriptive and individual psychological level, sociocultural factors are rarely discussed. This author will argue that, in contrast to somatization in non-Western cultures in which
113
somatoform disorders are often presentations of physical symptoms of mood or anxiety disorders, somatization in Western cultures appears more related to the medicalization and legalization of individual and social problems, interpersonal disconnectedness, unacknowledged trauma such as childhood sexual abuse, and a need to establish an individual identity in a culture that emphasizes individualism. This author further speculates that these same factors account for the presentation of dissociative identity disorders among the sector in contemporary Western culture in which distress is ‘‘psychologized’’ rather than ‘‘somatized’’.
Culture and somatization Kim H In Korea, many clinical studies found that somatization is a characteristic feature of depressive disorder and Hwabyung. But a few studies in the general population reported a low prevalence of somatization disorder. Many Korean psychiatrists have tried to explain the mechanism of somatization within the context of Korean culture. First, somatization is used as a method of maintaining dependency on their families, even during the adulthood. Second, somatization has a function of saving face. Maintenance of saving one’s face has played an important role in adaptation to Korean society. Third, the concept of illness in traditional (oriental) medicine has been suggested as a factor strongly influencing somatization. In traditional medicine, emotional problems are projected into the soma. Finally, ‘‘Noonchi’’ culture is considered a factor influencing somatization. ‘‘Noonchi’’ may be defined as knowing others’ mind by looking at them. Whether we have ‘‘Noonchi’’ or not is the key to good social relations in Korea. Therefore, ‘‘Noonchi’’ is likely to enhance the defensive role of somatization.
Somatic symptoms & depression: gender, cultural and historical issues in the construction of mental disorders (Chair) Bhui K, Rasul F, Jones E, Katja R, (Discussant) Bhugra D This symposium addressed the interplay between physical symptoms due to physical ill health and those due to mental ill health, in terms of cultural and gender variables. We explore physical complaints among post combat veterans, South Asians visiting health services, a population cohort examining cardiovascular disease, and physical complaints as part of explanatory models of mental distress. We propose cultural limitations on the way physical complaints are patterned as being a common characteristic across these broad areas of study. Depressive presentations are influenced both by cultural background, and the historical context, as well as gender.
A new instrument for the exploration of distress Ru¨dell K, Bhui KS, Priebe S Background: Patients suffering from emotional distress, depression or anxiety use often somatic metaphors and culture-specific symbolic language to communicate their feelings. Cross-cultural research has established that there are large cultural differences in patients’ perceptions of mental distress, but a comprehensive framework that conceptualizes these differences is missing. Methods: On the basis of an extensive literature review, a cross-cultural framework of distress was specified and extended until saturation was reached. Sixty-seven published qualitative ethnographic, anthropological, sociological, psychological and psychiatric accounts of distress from the world literature were treated as primary source ‘‘data’’ and used to identify initial categories of beliefs. Interpretative phenomenological analytic techniques, based on Kleinman’s and Leventhal’s theories, were used to derive further meaning and structure. Results: The new expanded framework of distress captures variations in expressions of distress in terms of sub-domains or clusters of beliefs. Thirty categories were initially extracted and consolidated to achieve the most
Symposium abstracts / Journal of Psychosomatic Research 55 (2003) 111–129
most recent phase has completed testing in over 60 practices as part of the RESPECT-Depression Project. Evaluation focuses on 6-month patient outcomes and the nature of the process of care. With the availability of successful clinical models, the primary challenges in the next phase are developing effective methods to disseminate and sustain these models of care. The dissemination strategy provides training as well as implementation strategies and tools to the quality improvement infrastructures of the partner health care organizations. Evaluation data is drawn from organizational administrative sources, participant surveys, direct observation of organizational decision making and dissemination processes, and key informant interviews.
Psychiatry and bioethics (Chair) Steinberg MD, Bostwick JM, Chen DT, Lederberg MS, Surman OS, (Discussant) Cohen MA Bioethical issues are a particularly intriguing and challenging aspect of the psychiatrists’ clinical work in the general hospital. C-L Psychiatry has historically been long involved in many of these issues, such as informed consent, truth telling and refusal of treatment, to the more recent ethical problems in end of life care, organ transplantation and others. C-L psychiatrists involvement in bioethics in the United States has ranged from psychiatric or bioethics consultant, ethics committee member or chair, to prominent roles in major ethics organizations, and journals. This symposium will provide a broad overview of psychiatry and bioethics. It will address the role of the psychiatrist as bioethics consultant, some of the most important areas of bioethical concern for the C-L psychiatrist, and consider how to train psychiatrists for their role in bioethics The speakers and discussant have all had extensive experience as C-L psychiatrists working in bioethics in major academic centers in the United States, and have made important contributions to the rapidly growing literature on psychiatric aspects of ethics.
The psychiatrist as bioethic consultant Lederberg MS Stressful situations often precipitate dysfunctional responses ranging from mild stress reactions to psychiatric decompensation in vulnerable individuals. The more complex the scenario, the more likely it will have an ethical dimension. Psychiatrists can bring a unique understanding of the nonrational factors that impinge on all human activities. But they need a precise awareness of the difference between exercising their clinical expertise and facilitating ethical decision-making. This paper outlines a schema for recognizing that distinction and illustrates ‘‘pseudoethics’’, ‘‘pseudo-psychiatry’’ and ‘‘psychiatry/ethics’’ consultations. It describes how to make a ‘‘situational diagnosis’’ that teases out (1) patient/families issues, (2) medical staff issues, (3)staff/patient interface issues, (4) legalregulatory issues and (5) ethical issues. This enables the psychiatrist to institute an appropriate ‘‘hierarchy of interventions’’: (a)educational, (b)psychological and (c)ethical. These will be described, along with a method of analyzing the ethical issues that emerge clearly once the situational diagnosis is completed.
Informed consent and live donor selection in organ transplantation Surman OS, Fukunishi I, Allen T, Findley J Organ donation from living donors was a source of ethical and psychological debate in the inchoate progress of kidney transplantation during the 1960s. Subsequent progress in transplantation biology, shortage of available cadaveric organs, rise in consumerism and decline in medical paternalism led been associated with increased acceptance of live donor participation. Has the pendulum swung too far? The inherent limitations
of informed consent and an excessive emphasis on autonomy/rights in donor selection are of great concern now that donors are being exposed to increased perioperative risk. We explore these considerations as they pertain to live donor partial right lobe transplantation.
Psychiatry and bioethics Chen DT, Rosenstein DL, Miller FG As other panel speakers have discussed, the practice of psychiatry in the general hospital setting is infused with bioethical issues. As Psychosomatic Medicine moves toward subspecialty status in the United States, issues of training psychiatrists for their role in identifying, managing, and resolving bioethical issues embedded in the practice of psychiatry in general hospitals will receive more formal attention than it does currently. Dr. Donna Chen recently completed formal postgraduate fellowship training in ‘‘Bioethics and Consultation – Liaison Psychiatry’’ cosponsored by the Psychiatry Consultation – Liaison Service, National Institute of Mental Health and the Department of Clinical Bioethics, National Institutes of Health — the first such formal training experience in the United States. From this perspective, she will discuss ways to incorporate bioethical content and processes into training for psychiatrists who serve as consultants in general medical and surgical settings. She will also discuss potentially new roles for psychiatrists in clinical research ethics activities.
Psychiatry and bioethics Bostwick JM When key terms lack definition, ethical discussion is obfuscated. In the medical arena, suicide is one such term in which overgeneralizations in the literature include several distinct entities under one blurry rubric. In a widely cited 1971 American Journal of Psychiatry article, Abram et al. declared that 5% of dialysis patients die by suicide. Subsumed in their definition of suicide were deaths by treatment noncompliance, treatment refusal, and treatment withdrawal. This presentation will offer a new taxonomy based on classifying self-destructive deaths according to two parameters: (1) whether the deceased intended death, and (2) whether others collaborated in the decision. As attitudes toward end-of-life options and decision making have evolved in the three decades since the Abram article, treatment withdrawal has become commonplace. Physician-assisted suicide and euthanasia are practiced in certain jurisdictions and hotly debated in others. The field of suicidology wrestles with distinctions between suicide and parasuicide, potentially life-threatening behavior for another purpose than ending life. With all these entities labeled suicide, the term fails to have either specificity or relevance. This taxonomy is offered in hopes of clarifying the nature of self-induced death in medical situations so that ethical discourse can better grapple with social and psychological complexities in life-ending acts.
Culture and somatization (Chair) Koh KB, (Presenters) Mak WWS, Kim HW, Hsu GLK, Koh KB, (Discussant) Tseng W Somatization is a universal psychopathology. Recent discussions of somatization have generally occurred on a descriptive and individual psychological level, but cultural factors are rarely discussed. Pattern of symptoms and its cultural factors in the conversion of emotional distress to the somatization are much different from culture to culture. The conventional impression that somatization is prevalent in the non-Western or traditional society and that it is due to poor differentiation of the psyche is seriously criticized. Cultural metaphors of expressing emotional pain, traditional disease concepts, conventional way of adopting a given culture and society, medical delivery
Symposium abstracts / Journal of Psychosomatic Research 55 (2003) 111–129 system, and milieu could be regarded as important cultural factors of somatization. In this symposium, we are going to review and discuss 4 subtitles: Somatization in the Chinese Diaspora, Korean Culture and Somatization, Western Culture and Somatization, and Anger and Somatization.
Anger and somatization Koh KB Repressed hostility and anger has been described as crucial factors in somatization. Hwa-byung is known to be an anger syndrome specific to Korean culture that is characterized by anger suppression resulting in specific somatization. In this study, the relationship between anger expression and somatic symptoms in each group of depressive disorders, anxiety disorders, somatoform disorders, and psychosomatic disorders was examined. The subjects included patients with depressive disorders, patients with anxiety disorders, patients with somatoform disorders, patients with psychosomatic disorders, and normal controls. The Anger Expression Scale was used to assess the anger expression or suppression. The Somatization Rating Scale was used to assess the level of somatic symptoms. The severity of depression, anxiety, and somatization were assessed using the SCL-90-R. Within the depressive disorder group, the severity of somatization more strongly correlated with the anger-out score compared to the anger-in score, whereas, in the somatoform disorder, anxiety disorder, and psychosomatic disorder groups, the severity of somatization significantly correlated with the anger-in score. These results suggest that anger expression is likely to be predominantly associated with somatization in depressive disorder patients, whereas anger suppression is likely to be associated with somatization in anxiety disorder, somatoform disorder, and psychosomatic disorder patients.
Culture and somatization Mak WW, Cheung FM Somatization is a form of contextualized response to emotional responses that is common among Chinese populations. Based on results from the normative sample of the Chinese Personality Assessment Inventory (CPAI) in Mainland China and Hong Kong (N = 2444) somatization showed a strong interpersonal disposition, with the highest loadings from the Dependability and Interpersonal Relatedness factors. In the restandardization normative sample (N = 1911), almost all of the personality scales of the CPAI-2 were significantly correlated with somatization. These results pointed to the importance of indigenous personality traits in the manifestation of psychopathology. Acculturation can moderate Chinese Americans’ somatization tendencies as they increasingly adopt American illness behaviors. Using data from the Chinese American Psychiatric Epidemiologic Study (CAPES) (N = 1747) it was found that length of residence in the United States and acculturation were not related to somatization. Somatization was significantly influenced by individuals’ level of depression and anxiety, gender, age, education, stress, and instrumental support. Thus, it might be a stress response to heightened distress severity and psychosocial stressors rather than a cultural response to express psychological problems in somatic terms. Our recent studies highlighted significant proximal factors in the explanation of somatization tendencies among the Chinese diaspora.
Somatization in the West Hsu LG By definition, somatoform disorders are presentations of bodily symptoms which have no demonstrable physical origins. Recent discussions of these disorders have generally occurred on a descriptive and individual psychological level, sociocultural factors are rarely discussed. This author will argue that, in contrast to somatization in non-Western cultures in which
113
somatoform disorders are often presentations of physical symptoms of mood or anxiety disorders, somatization in Western cultures appears more related to the medicalization and legalization of individual and social problems, interpersonal disconnectedness, unacknowledged trauma such as childhood sexual abuse, and a need to establish an individual identity in a culture that emphasizes individualism. This author further speculates that these same factors account for the presentation of dissociative identity disorders among the sector in contemporary Western culture in which distress is ‘‘psychologized’’ rather than ‘‘somatized’’.
Culture and somatization Kim H In Korea, many clinical studies found that somatization is a characteristic feature of depressive disorder and Hwabyung. But a few studies in the general population reported a low prevalence of somatization disorder. Many Korean psychiatrists have tried to explain the mechanism of somatization within the context of Korean culture. First, somatization is used as a method of maintaining dependency on their families, even during the adulthood. Second, somatization has a function of saving face. Maintenance of saving one’s face has played an important role in adaptation to Korean society. Third, the concept of illness in traditional (oriental) medicine has been suggested as a factor strongly influencing somatization. In traditional medicine, emotional problems are projected into the soma. Finally, ‘‘Noonchi’’ culture is considered a factor influencing somatization. ‘‘Noonchi’’ may be defined as knowing others’ mind by looking at them. Whether we have ‘‘Noonchi’’ or not is the key to good social relations in Korea. Therefore, ‘‘Noonchi’’ is likely to enhance the defensive role of somatization.
Somatic symptoms & depression: gender, cultural and historical issues in the construction of mental disorders (Chair) Bhui K, Rasul F, Jones E, Katja R, (Discussant) Bhugra D This symposium addressed the interplay between physical symptoms due to physical ill health and those due to mental ill health, in terms of cultural and gender variables. We explore physical complaints among post combat veterans, South Asians visiting health services, a population cohort examining cardiovascular disease, and physical complaints as part of explanatory models of mental distress. We propose cultural limitations on the way physical complaints are patterned as being a common characteristic across these broad areas of study. Depressive presentations are influenced both by cultural background, and the historical context, as well as gender.
A new instrument for the exploration of distress Ru¨dell K, Bhui KS, Priebe S Background: Patients suffering from emotional distress, depression or anxiety use often somatic metaphors and culture-specific symbolic language to communicate their feelings. Cross-cultural research has established that there are large cultural differences in patients’ perceptions of mental distress, but a comprehensive framework that conceptualizes these differences is missing. Methods: On the basis of an extensive literature review, a cross-cultural framework of distress was specified and extended until saturation was reached. Sixty-seven published qualitative ethnographic, anthropological, sociological, psychological and psychiatric accounts of distress from the world literature were treated as primary source ‘‘data’’ and used to identify initial categories of beliefs. Interpretative phenomenological analytic techniques, based on Kleinman’s and Leventhal’s theories, were used to derive further meaning and structure. Results: The new expanded framework of distress captures variations in expressions of distress in terms of sub-domains or clusters of beliefs. Thirty categories were initially extracted and consolidated to achieve the most