Psychosomatic Disorders in Prospective Immigrants to Canada

Psychosomatic Disorders in Prospective Immigrants to Canada An Epidemiological Study W. C.

BURROWS,

M.D., F.R.C.P.(C), D.P.M., F.A.P.A.

• Immigration into Canada is controlled by the Canadian Immigration Act of 1952U and prospective immigrants are medically examined in terms of its provisions. This Act rejects as immigrants individuals suffering from (or with history of) certain illnesses and serious personality defects. Those suffering from (or with history of) certain other less serious conditions (which include in the psychiatric sphere the psychoneuroses, psychosomatic disorders and certain personality defects) may be accepted suhject to various factors such as prognosis, possession of desired skills, adequate financial hackgrOlmd, sponsorship in Canada, et cetera. Medical examination of prospective immigrants outside Canada is one of the responsihilities of the Immigration Medical Service of the Department of Kational Health and Welfare. Its offices and Canadian physicians are located in various major cities outside the Iron Curtain countries. This present study is concerned with its European operation, the headquarters of which is in London, England, where the author serves as psychiatric consultant. Medical examination is mandatory for all prospective immigrants. The physician reports his diagnosis where physical or psychiatric disorder (or history thereof) is discovered; if the diagnosis is not of a prohihitive nature, a prognosis and assessment of risk are also required. The approach is essentially practical. Prognostic standards for psychiatric conditions From the Department of National Health and Welfare, Canada, London, England. Presented at the Eleventh Annual Meetin~. Academy of Psychosomatic Medicine, New York City, October, 1964.

156

tend to he on the empirical side, as little has yet been reported from Canada on the ultimate mental health of migrant groups. Numerous studies are currently in progress;" some follow-up studies already reported suggest that medical examiners overseas may well he overly optimistic in estimates of prognosis. I The relationship between migration and psychiatric illness has interested researchers for some decades and a wealth of pertinent literature exists. Mental illness has heen considered in relationship to cultural milieu" and ethnic origin." Radzinski has graphically descrihed how the social stresses produced in a host-country hy uncontrolled immigration result in social deterioration and disorders. 7 Tyhurst, studying displacement and migration, had highlighted the effects of vertical movement on the social side as well as geographical removal, noting a higher incidence of neurotic breakdown in displaced persons compared to true immigrants.' The traumatic effect of transposition to a foreign cultural milieu has heen described," and the concept of "culture-shock" propounded. Humanitarian agencies have stated that it is not only morally wrong but unreasonahle for a host-country to accept only immigrants of perfect mental health, hut other authors lO point out that poor selection criteria can result in serious social and mental health problems for the host-country. Psychiatric screening of prospective immigrants is carried out hy most of the major host-countries and these techniques have been reported. I l · 1" Epidemiological studies have been reported t3 . H and specific types of psychiatric disorder in immigrant groups investigated, e.g. psychosis,15<17 psychoneurosis,I'.ln alcoholism,20 hypochondriasis. 21 Psychodynamic processes in Volume VI

IMMIGRANTS TO CANADA-BURROWS

both migrant and host groups have been considered 22 and defence reactions amongst immigrant casualties considered from the point of view of ethnic origin. ' I. 11 ,IH.21.2;I,24 Odegarde ' " has suggested as regards schizophrenic breakdowns that the immigrant group contains a higher percentage of "susceptibles" than does a matched non-immigrant population, a state of affairs which would seem to exist for other disorders as well. The emotional symptoms relating to isolated groups have been studied,20 The extension of man's environment into outer space has highlighted the importance of isolation and communication, and a wealth of experimental data has been accumulated. These are not without significance to the social psychiatrist concerned with the mental health of migrant groups. Voluminous as is the literature dealing with psychosomatic disorders, relatively little has been written of their relationship to migration. Existing reports, in the main, relate the social stresses and cultural conflicts of migration with the development of psychophysiological reactions;2G'''2 or discuss specific conditions in a displaced population, e.g. thyrotoxicosis,~3 hypertension,;\4 asthma,~'-' gynecological disorders""·;" and others."'" In any international study of psychosomatic disorders, the initial problem is one of semantics, since little agreement exists as to what disorders are "psychosomatic." The author. trained in American dynamic psychiatry and conversant with its nomenclature and diag· nostic criteria,~H encountered subtle differences of opinion in Britain."'·I' Psychiatric concepts in the various European countries had their own national differences; in some medicallvunsophisticated areas the psychosomatic CO;lcept was scarcely reco~nized hy orthodox medicine. One might reasonably query whether any disease exists which is not "psychosomatic" in the full sense of the term; but since limits were necessary, it was decided to screen for those conditions described as "Psycho-physiological Reactions" by the American Psychiatric Association. 42 Proven cases of peptic ulceration and the allergic diatheses have been included. but in deference to European opinion such entities as coronary artery disease, rheumatoid arthritis, diabetes mellitus and thyrotoxicosis were not. In the case of essential hypertension May-J~me,

1965

the criteria used were those of the Immigration Medical Service.'" Elevated blood pressure readings were rechecked after twenty minutes' rest in the recumbent position; where practical, three daily repeated readings were ohtained from the immigrant's physician. In such a study as this, one would like to answer the following questions: 1. Do the personalities of prospective Canadian immigrants differ significantly from those of a similar matched non-immigrant population?

2. Do the psychodynamics and personalities of prospective immigrants predispose to the development of psychosomatic disorders?

3. Does the prevalence of psychosomatic disorders in the immigrant population differ from that of the non-immigrant population? Regrettably, one must admit that the present study can make no claims to answering these questions. The physical process of medical examinations makes personality study of the immigrants impossible except in certain selective cases; setting-up of matched nonimmi~rant control groups is also impossible. The population studied is drawn from European areas where statistics as to prevalence of psychosomatic disorders are not available, "'hile attempts are made to compare the rate encountered in one small selected sub-group of immigrants with a similar population of nonimmigrants, the matching of the samples is far from satisfactory. ]\'0 conclusions can be drawn. This paper reports on the prevalence of individuals suffering from (or with history of) certain disorders widely considered to he psychosomatic. The population surveyed consisted of 47,212 prospective immigrants to Canada from "'estern Europe, examined in Europe in Canadian medical offices and/or by Canadian physicians, during the five-month period April through August, 1964. The diagnoses were made by the medical examiners, supported hy hospital, clinic or local consultants' reports where available, and in every case concurred in by the author. The history (in a small percentage of individuals) of multiple psychosomatic disorders occurring at different 157

PSYCHOSOMATICS

periods of life is in keeping with Halliday's postulations. 40 In the period of study, 1,142 individuals were identified as suffering from (or with history of) the psychosomatic disorders concerned. Of these, 605 were male and 537 female. This represents a prevalence rate of 24.19 per 1,000 immigrants and a Male:Female ratio of 1.31: 1. Multiple psychosomatic disorders were encountered in 22 individuals, 11 male and 11 female. A detailed breakdown of these data is presented in Table I. TABLE 1.

PSYCHOSOMATIC REACTIONS

Diagnosis

Total

:Male

Female

CaSt'S

P. P.

!iIi

Dcrmatol. Reactions Musculo.

:18

~

Reactions P. Resp. Reactions P. Cardiovas. Reactions P. H.&L. Reactions P. Gastro. Reactions P. Gen.·l'r. Reactions P. Enduer. Reactions P. :'\c,>n:. Sy,. Reactions P. Spec. Sen. Reactions

Rate per 1l~)()

._--28 1.39

:l

.08

~'9

12

17

.61

:Ill

25

t:1

.80

II

.U2

Ii

~

.13

Aller~ic

li8

114

64

Peptic

215

182

:l:l

~.55

H~~~~?;::~n ----

627

240

38i

t:l.28

Diathesis

UIC('f

._--

--_.

TOTAL

1142

605

3.i7

537

-------

..

-

Standard medical textbooks describe the average blood pressure for a group of healthy persons as being about 120/80 at the age of twenty, rising to 160/90 at the age of sixty.41 The Joint Committee of the Association of Life Insurance Medical Directors and Actuarial

:\~e

Grout>

Total

In this study, hypertension was diagnosed in the presence of a persistently elevated diastolic pressure of 90 or over in applicants under thirty; or 100 or more in applicants under fifty; and of 110 or more at any age. I:! It would perhaps be more scientifically accurate to record that the 627 cases detected (out of the total of 1142 cases of psychosomatic disorders) suffered from "significantly elevated blood pressure" rather than from essential hypertension, for in many cases it has been impossible to obtain repeated daily blood pressure readings and/or other clinical investigation. One may perhaps sugg{'st that these figures attest to the anxietyproducing nature of the immigration examination, which, particularly to immigrants from peasant and/or economically depressed areas, is a source of great apprehension. Breakdown of these data is shown in Table II.

24.19 --

ESSENTIAL HYPERTENSION

TABLE II.

Managers of America has demonstrated that levels of blood pressure higher than 140 systolic and 90 diastolic are abnormal at any age. Life insurance studies show that a large proportion of instances of hypertension have their onset in the thirties and early forties, with relatively few persons developing consistent hypertension for the first time at age fifty-five or older. Women, though subject to hypertension more frequently, are not so susceptible to its damaging effects, the annual mortality rates being 41 per 1,000 in men and 20 per 1,000 in women. I.;

PEPTIC ULCER

Fry,ll; reporting on the cases of peptic ulcer diagnosed and followed up through a fifteenyear period in an urban British general practice (mainly, Registrar-General's Social Classes II, III, and IV, and mean size 6,385 persons), lists 265 cases. (Cumulative prevalence rate was 5.3 per cent, annual incidence rate 4.2 per 1,000. and annual prevalence rate 16 per

ESSENTIAL HYPERTENSION Male

Female

~I.:F.

Ratio

Rate per 1000

243 12 44 i1 44 49 20 3

3AA :l 24 42 59 152 78 26

.63:1

13.28

Cast's

17·88 15-~-t

25·3·' :l5··H 45·;)·\ 55·64 65·i4 75·88

158

6?" .1 15 68 113 103 201

98 29

~:I

1.83: 1 1.69: 1 .i5: 1 .32: I .26: I .12: 1

Volwne VI

IMMIGRANTS TO CANADA-BURROWS TABLE III. A~e

Group

Total

PEPTIC ULCERATION

Male

Female

Cases

3·79 :1·15 15·24 25·34

214 I 30 76

3:)·44

~2

45-54 55·64 '.5-79

22 III 15

181 24 69 42 20 13 13

1,000. ) Duodenal ulcerations accounted for 212. 176 males and 36 females (M: F ratio = 4.9: 1). Gastric ulceration accounted for 53, 28 male and 25 female (M: F ratio = 1.1: 1 ). Current medical authorities 41 report the incidence of gastric ulcer to be evenly distributed between the sexes, while that of duodenal ulcer is three to four times as high for males. They suggest that 10 per cent of the population will suffer from peptic ulceration during their lifetime. Life insurance figures,4' based on a London study by Dahl and Jones report. in the age group 14 to 64 years, an incidence of neptic ulceration of 5.8 per cent in males to 1.9 per cent in females. Documentation on some cases from certain Continental countries was not sufficiently complete to warrant accurate differentiation between gastric and duodenal ulceration. In the present study, therefore, cases of neptic ulceration are not so differentiated. A breakdown of the fignres for this condition is shown in Table III. This crude epidemiological study permits of no conclusions: several observations may perhaps be made. 1. Prevalence rates reported are probably low for several reasons: ( a) Prospective immigrants, to a varying degree, put on as good a front as possible, minimizing or denying relevant medical history. (This tendency, commoner in some ethnic groups than others, tends to tum psychiatric screening into a battle of wits.) Incidence of illness reported may be as much a reflection of the honesty of immigrants as of their health. (b) In some areas, co-operation of local hospitals and practitioners as regarding provision of past medical history is minimal; indeed, in some European countries it is not only unethiMay-June, 1965

33 1 6 7 10 2 2

M.:F.

Rate

Ratio

per 1000

~.48:1

4.53

4: I

9.9: I 4.2: I 10: I 2.6: I 6.5:1

cal but a criminal act for a doctor to give, even with his patient's consent, and to a fellow practitioner, a report which may in any way be used to the detriment of the patient. 2. Applicants from economically-depressed areas look on migration as their one chance to reach the Promised Land; those from backward, isolated peasant communities may be makin~ the first visit of their lives to a large city when they come fonvard for examination. It would be reasonable to conclude that for such as these the experience is a source of apprehension, contributing to the elevation of hlood pressures and the activation of individuals of low anxiety tolerance. 3. Epidemiological studies relating psychosis, neurosis and various characteriological illnesses to the immigrant population have tended to suggest the presence of a higher percentage of sllsceptible individuals than occurs in a nonimmigrant control population. AIthou~h matched controls are outside the scope of the present study it does not dispel the suspicion that the same may be true as regards psychosomatic disorders. ACK:"OWLEDG:\!EN"TS

I shollld like to acknowledge my indebtedness to Professor E. D. \Vittkower, Department of Psychiatry. McGill University. Montreal, Canada, and to Professor Denis Hill, Academic Psychiatric Unit, Middlesex Hospital Medical School, London, England, for their advice and guidance; to Dr. P. E. Moore, Director of Medical Services, Department of National Health and Welfare, for permission to publish this report; to Dr. R. J. F. H. Pinsent, of the College of General Practitioners, London, and the Actuarial Staff of the London office of the Sun Life Assurance Company of Canada; to Dr. J. E. Grant, Regional Superintendent, European Region, for his suggestions and encour159

PSYCHOSOMATICS

agement; and to my London colleagues Dr. G. D. McQuade, Dr. N. S. Black, and Dr. L. L. Palmer for their assistance throughout this study. REFERENCES

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