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Somatization: A transcultural study
Journal of Psychosomatic Research, Vol. 39, No. 7, pp. 883-888, 1995 Copyright © 1995 Elsevier Science Inc. Printed in Great Britain. All rights reserved. 0022-3999/95 $29.00 + 0.00
Pergamon
0022-3999(94)00034-3
SOMATIZATION: A TRANSCULTURAL STUDY S A E E D F A R O O Q , M A N J I T S. G A H I R , E B E N E Z E R O K Y E R E , A. J A W A D S H E I K H and F E M I O Y E B O D E * (Receivedfor publication 10 January 1994; accepted 9 March 1995) Abstract--The primary aim of this study was to investigate the comparative rates of somatic complaints between Asian and Caucasian patients in a primary care setting and to characterize the factors associated with increased rates of somatization. One hundred and ninety-fiveindividuals aged between 16 and 65 yr were interviewed with the Bradford Somatic Inventory (BSI) and the Hospital Anxiety and Depression Scale (HAD) respectively. The main finding was that the Asian patients reported significantly more somatic and depressive symptoms than the Caucasian patients. Ethnicity was the most important variable determining this result. Keywords: Somatization; Depression; Anxiety; Ethnicity.
INTRODUCTION Patients with persistent somatic symptoms which have no accompanying pathological findings pose diagnostic and therapeutic problems for health care professionals. The term somatization, which is used to describe this phenomenon, has been defined as the "expression of personal and social distress in an idiom of bodily complaints" in association with medical health-seeking behaviour [1]. There are several studies which report that emotional distress is expressed in somatic terms in developing countries [1-6] and furthermore, that this is in contrast to patients from the Western world who are able to communicate their distress in psychological terms [7, 8]. There are studies, on minority ethnic groups who derive from the developing world but who live within the Western world, which report that these groups are also more likely to present with somatic rather than psychological symptoms in the primary care setting [9, 10]. These findings have led to various explanations including the claim that contemporary non-Western cultures not only lack words for anxiety and depression, but also that individuals in these cultures experience emotions in an undifferentiated way [8, 11]. This explanation must be treated with caution. There is a growing literature demonstrating that in the U.S.A. and U.K. at least half of all patients in the primary care setting with a diagnosable psychiatric disorder present with somatic rather than psychological symptoms [12, 13]. This suggests that somatization is not restricted to individuals from non-Western cultures. The other possible explanation is that there are individuals who, irrespective of their cultural origins, have no words * Author to whom correspondence should be addressed at: Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2QZ, U.K. 883
884
S. FAROOQ et al.
for feelings. The term alexithymia is used to describe this phenomenon [14]. The validity of this concept is also in doubt [15]. There are a number of methodological difficulties associated with cross-cultural comparisons. Most notably, research instruments which are developed in one culture and applied to another culture need to be properly validated. This process means much more than back-translations of research instruments into target languages. This point is well illustrated by Krause's [16] comment: "In the course of administering GHQ, I have been asking Punjabis settled in Britain if they feel there is hope in life, and the answers I have received range from somewhat defensive laughter about the stupidity of the question, because 'it is not for us to have hope', . . .". It may be that a number of symptoms are not endorsed, not because the patients are symptomfree in that area, but that the "language used is not such in terms of which these patients feel or think" [17]. The general aim of the present study was to investigate the comparative rates of somatic complaints in a primary care setting between a sample of Asian patients resident in Britain and a sample of indigenous Caucasian British patients. The secondary aims were to delineate the relationship between somatic complaints and emotional disorder and to characterize the factors associated with increased rates of somatization.
METHODS A sample of 195 patients drawn from two general practice surgeries, and aged between 16 and 65 years, were interviewed over a 4-wk period in 1993. Consecutive attenders at the surgeries over the study period were approached to participate in the study and the sample was made up of those who agreed to complete the questionnaires. In order to reduce any systematic bias patients attending either morning or evening clinics respectively were eligible for inclusion in the study. This strategy was employed because it was recognized that the morning clinics were favoured by mothers and children whereas the evening clinics had a larger proportion of men. One surgery was located in an inner city electoral ward and the practice list was made up, predominantly, of patients who originated from India and Pakistan. The other surgery was located in an outer city electoral ward and the practice list was made up, predominantly, of patients who were native Caucasian British. Two interviewers (SF & JS) interviewed all the Asian patients whose interviews were administered in Asian languages. The Bradford Somatic Inventory (BSI) and Hospital Anxiety and Depression Scale (HADs) were administered to the subjects. The BSI was constructed simultaneously in Urdu and English and has been validated in field studies conducted in Pakistan [18, 19]. The HAD was designed for use in medical outpatient clinics [20] and has been translated into Urdu and found to be reliable and valid [21]. The HAD was used in this study because the items in it are constructed from psychological rather than somatic complaints. This is desirable in a study investigating the relationship between psychological and somatic complaints. Both instruments are self-completed questionnaires, but were read out to subjects who were illiterate. This procedure safeguarded against a systematic bias of excluding illiterate subjects from the potential research population. Data, including demographic details, place of birth, and education, occupation and employment status were also gathered. In this study Asian was defined as people originating from India, Pakistan, and Bangladesh irrespective of place of birth.
RESULTS
One hundred and ninety-five patients participated in the study. There was 108 (55.4%) Caucasian patients and 87 (44.6%) Asian patients. Only 16 (18.4%) of the Asian subjects were born in the U.K. The majority (61%) were born in Pakistan, 16 (18.4%) were born in the U.K., 6 (8.4%) in India, 8 (11.2%) in Bangladesh, 4 (5.6%) in Africa, 1 (1.4%) in Ireland; whereas the majority of the Caucasian patients (104;
885
Somatization: A transcultural study Table l.--Study group characteristics Variable
Born in U.K. Mean age (yr) No. male subjects No. unemployed No. married No. illiterate
Asian (n = 87) 16 33.8 46 27 66 21
(18.4%) (SD 15,6) (52.9%) (32.2%) (75.9%) (24.1%)
Caucasian (n = 108)
Statistic
p value
104 (96.2%) 41.8 (SD 14.6) 35 (32.4%) 8 (7.4%) 73 (67.6%) 0 (0%)
X2 = 123.6 (dfl) t = 3.66 (df178) X2= 8.31 (dfl) X2 - 18.63 (dfl) X- = 5.61 (dfl) Z2 = 32.98 (dfl)
<0.001 <0.001 <0.004 <0.001 0.2 <0.001
96.2%) were born in the U.K. The mean age of the Asian subjects was 33.8 yr (SD 15.6) and the mean age of the Caucasian subjects was 41.8 yr (SD 14.6). The Asian sample had significantly more male patients and the proportion of unemployed individuals was significantly greater in this group. Twenty-one (24%) Asian subjects were illiterate whereas none of the Caucasian patients was illiterate. There was no significant difference in the marital status of patients from both ethnic groups. (Table I). The mean BSI score was significantly higher in the Asian subjects. The mean score on the depression subscale of H A D was also significantly higher in the Asian subjects whereas the mean score on the anxiety subscale of H A D was no different between the groups (Table II). Twenty-six (29.9%) Asian subjects were "cases" if a cut-off point of greater than 10 on H A D anxiety subscale was the criterion for "caseness" compared to 30 (27.8%) Caucasian subjects. This finding was not significantly different. With respect to the H A D depression subscale, using a cut-off score of greater than 10, there were 14 (16%) Asian subjects meeting the criterion for "caseness" and 5 (4.6%) Caucasian patients. This difference was statistically significant (Chi-square = 7.20; p = 0.007). As a group the unemployed subjects had a mean H A D depression subscale score of 6.68 (SD 4.16) compared to 4.67 (3.69) in the employed. This difference was significantly higher (t = 8.09; p = 0.005), whereas no statistical differences were observed in the scores on H A D anxiety subscale and BSI respectively between the groups. There were no significant associations between gender and scores on any of the scales. Multiple regression of the total BSI score was carried out taking ethnicity, education and employment as the independent variables. This showed that ethnicity had the
Table II. Variable Mean Total HAD-Anx (SD) Mean Total H A D - D e p (SD) Mean Total BSI (SD)
Mean scores on HADS & BSI
Asian
Caucasian
Statistic
p value
7.43 (5.11 )
8.14 (4.25)
t - 1.04 (df166)
0.3
5.99 (4.15)
4.22 (3.37)
t - 3.21 (df164)
0.002
19.5 (16.0)
15.6 (11.2)
t = 1.95 (dfl48)
0.05
886
S. FAROOQ et al. Table III.--Correlations between scores on HADS & BSI Ethnicity Asian Caucasian
HAD-Anx/BSI r(CI) 0.72 (0.6
HAD-Dep/BSI r(CI) 0.53 (0.36
strongest correlation (Beta - 0.11; p = 0.16) compared to education (Beta 0.019; p = 0.7) or employment (Beta -0.06; p = 0.4). The same analysis was carried out for the depression subscale of HAD. Ethnicity was shown to have the strongest correlation (Beta -0.17; p -- 0.02) compared to education (Beta -0.08; p = 0.3) or employment (Beta -0.09; p = 0.2). In the Asian patients the correlation coefficient between scores on BSI and HAD anxiety subscale was 0.72 and between scores on BSI and HAD depression subscale was 0.53. In the Caucasian group the correlations were 0.48 and 0.53 respectively (Table III). In the Asian sample, the correlation coefficient of the subscales of HAD was 0.60 (CI 0.46
Somatization as measured by the BSI is a common phenomenon in primary care, and Asian patients report more of these somatic symptoms than Caucasian patients. Multiple regression, showed that ethnicity was the most important variable associated with higher scores on the BSI. In addition, the Asian patients reported significantly more depressive symptoms and there were significantly more "cases" of depression compared to Caucasian patients. It was notable that it was anxiety scores which were most correlated with the frequency of somatic complaints. There are other studies, which like ours, report increased rates of somatic complaints in Asian patients in primary care settings [10, 22]. These studies also showed that the somatic complaints were accompanied by psychological complaints, and in one study that there was a linear relationship between somatic complaints and anxiety and depressive complaints respectively [10]. This was replicated in our finding of positive correlations between BSI scores and H A D depression and anxiety subscale scores respectively. It is important to emphasize, though, that it was anxiety scores which were most strongly correlated to somatic complaints. These linear relationships suggests that somatic complaints should be regarded as parallel and equally valid expressions of distress, rather than as a defence against the awareness of affect [15]. We also found that the correlation coefficients between the anxiety and depression subscales of H A D were not dissimilar between the two ethnic groups. This finding undermines Left's hypothesis [11] of emotional undifterentiation in non-Western peoples. Some of our findings, notably the increased rates of depression "cases" in the Asian sample are at variance with some previous reports [23]. The earlier reports of lower rates of emotional disorders among patients of Indian and Pakistan origin were derived from hospital admission figures [24, 25]. The validity of these reports
Somatization: A transcultural study
887
is necessarily limited by their reliance upon admissions rates as markers of morbidity levels within populations. It has been suggested that age, gender, social class, and education may contribute to the determination of somatization [26], and also that unemployment may have an influence upon psychosomatic symptoms [27]. In our study, gender, age and employment status did not appear to be particularly related to frequency of somatic complaints whereas ethnicity appeared to be the most important determinant of somatic complaints. The sociodemographic differences between the Asian and Caucasian subjects in our study probably reflect the social and economic characteristics of the immigrant population from the Indian subcontinent. The low proportion of female patients presenting in general practice surgeries is well recognized [24, 28] and suggests either that there is a reluctance on the part of Asian females to attend surgeries or that there is a genuine difference in the levels of morbidity between males and females in this population. In other words that women do not present at surgeries because they are more robust and healthier than their male counterparts. We do not believe that the latter explanation is likely to be correct. The determinants of this relative absence of Asian female patients at primary care centres deserve further study. The disproportionately high levels of unemployment in the Asian sample confirms the widely held view that individuals from immigrant populations suffer social disadvantage, such as unemployment, much more than indigenous populations. Our study suggests that there may be demonstrable emotional burden, in the form of depression, associated with this social disadvantage. This relationship between unemployment and depression has been noted in previous studies [27]. There are obvious methodological problems with our study. We acknowledge that objective data about the patients' physical health were unavailable and that therefore, the relationship between somatic complaints and genuine physical diseases is unknown. However, it is recognized that a thorough physical assessment often cannot unequivocally aid the assignation of somatic complaints to either physical or psychological disorder [26]. On the basis of our study, it appears that there is a modest difference in the frequency of somatic symptoms expressed between the two ethnic groups investigated. However, these differences seem to be less pervasive than is generally thought to be the case. The somatic complaints are related both to depressive and anxiety symptoms. The challenge to health professionals is to understand the complex interplay of factors which determine how one individual will express his distress. If our findings are confirmed, it would also appear that there is considerable psychiatric morbidity in the Asian population which is obscured by hospital admission data. Whilst it has been suggested that doctors may need to change the patient's attributions for optimal management of somatization [13], it seems to us that the aim should also be to change the doctor's attribution of what a patient presents with, rather than simply to encourage the patient to present with what the physician thinks he ought to present with. Acknowledgements We acknowledge the co-operation of our general practice colleagues Drs Houghton, Rumsey, Singhal, Young and Shah who gave us access to their surgeries and patients.
888
S. FAROOQ et al. REFERENCES
1. KLEINMAN A. Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry 1982; 6: 117-120. 2. BINITIE A. A factor analytic study of depression across cultures (African and European). Br J Psychiatry 1975; 127: 559-563. 3. JEGEDE RO. Outpatient psychiatry in an urban clinic in a developing country. Soc Psychiatry 1875; 13: 93-98. 4. EBIGBO PO. Development of culture specific (Nigeria) screening scale of somatic complaints indicating psychiatric disturbance. Cult Med Psychiatry 1982; 6: 2943. 5. M A R S E L L A AJ. Cross-cultural research on severe mental disorders: issues and findings. Acta Psychiatr Scand Suppl 1987; 344: 78, 7-23. 6. S A X E N A S, NEPAL MK, MOHAN D. DSM-III: Axis I diagnosis of Indian psychiatric patients presenting with somatic symptoms. Am J Psychiatry 1988; 145: 1023-1024. 7. JABLENSKY A, SARTORIUS N, GULBINAT W, ERNBERG G. Characteristics of depressive patients contacting psychiatric services in four cultures. Acta Psychiatr Scand 1981; 63:308 318. 8. LEFF JP. Psychiatry Around the Globe. a Transcultural View, Second Edn. London: Gaskell, 1988. 9. BAL SS. Psychological symptomatology and health beliefs of Asian patients. In Clinical Psychology. Research and Developments (Edited by Dent H), pp. 101-110. London: Croom Helm, 1987. 10. MUMFORD D. Somatisation: a transcultural perspective. Int Rev Psychiatry 1993; 5: 231-242. 11. LEFF JP. Culture and the differentiation of emotional states. Br J Psychiatry 1973; 123:299 306. 12. LIPOWSKI ZJ. Somatization, the concept and its clinical application. Am J Psychiatry 1988; 145: 1358-1368. 13. GOLDBERG DP, BRIDGES RN. Somatic presentation of DSM-III psychiatric disorder in primary care. J Psychosom Res 1988; 32: 563-569. 14. LESSER IM. Current concepts in psychiatry: alexithymia. N Engl J Med 1985; 312:690 692. 15. SIMON GE, VONKORFF M. Somatization and psychiatric disorder in the NIMH epidemiologic catchment area study. Am J Psychiatry 1991; 148:1494-1500. 16. KRAUSE lB. Sinking heart: a Punjabi communication of distress. Soc Sci Med 1989; 29: 563-575. 17. WlGG NN, VERMA SK. A cross-cultural study of psychiatric patients on Cornell Medical Index. Ind J Psychiatry 1973; 15:363 366. 18. M U M F O R D DB, BAVINGTON JT, BHATNAGAR KS, HUSAIN Y, MIRZA S, NARGHI MM. The Bradford Somatic Inventory. A multiethnic inventory of somatic symptoms reported by anxious and depressed patients in Britain and Indo-Pakistan subcontinent. Br J Psychiatry 1991; 158: 379-386. 19. M U M F O R D DB, TAREEN 1AK, BHATTI MR, BAJWA MAZ, AYUB M, PERVEZ T. An investigation of 'functional' somatic symptoms among patients attending medical clinics in Pakistan II. Using somatic symptoms to identify patients with psychiatric disorders. J Psychosom Res 1991; 35: 257-264. 20. ZIGMOND A, SNAITH RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361-370. 21. M U M F O R D DB, TAREEN IAK, BAJWA MZ, BHATTI MR, KARIM R. The translation and evaluation of an Urdu version of the Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1991; 83: 81-85. 22. BHATT A, TOMENSON B, BENJAMIN S. Transcultural pattern of somatisation in primary care: a preliminary report. J Psychosom Res 1989; 33: 671~80. 23. COCHRANE R, STOPES-ROE M. Psychological symptom levels in Indian immigrants to England: a comparison with native English. Psychol Med 1981; 11:319 327. 24. COCHRANE R. Mental illness in immigrants to England and Wales. Soc Psychiatry 1977; 12:23 35. 25. DEAN G, WALSH D, DOWNING H. First admission of native born and immigrants to psychiatric hospitals in South East England. Br J Psychiatry 1981; 119: 253-260. 26. ESCOBAR Jl, BURMAN MA, KARNO M, FORSYTH A, GOLDING JM. Somatization in primary care. Arch Gen Psychiatry 1987; 44:713 718. 27. VIINAMAKI H, KOSKELA K, NISKANEN L. The impact of unemployment on psychosomatic symptoms and mental well-being. Int J Soc Psychiatry 1993; 39: 266-273. 28. BREWIN C. Explaining lower rates of psychiatric treatment among Asian immigrants to the United Kingdom: a preliminary report. Soc Psychiatry 1980; 15: 17-19.
Pergamon
0022-3999(94)00034-3
SOMATIZATION: A TRANSCULTURAL STUDY S A E E D F A R O O Q , M A N J I T S. G A H I R , E B E N E Z E R O K Y E R E , A. J A W A D S H E I K H and F E M I O Y E B O D E * (Receivedfor publication 10 January 1994; accepted 9 March 1995) Abstract--The primary aim of this study was to investigate the comparative rates of somatic complaints between Asian and Caucasian patients in a primary care setting and to characterize the factors associated with increased rates of somatization. One hundred and ninety-fiveindividuals aged between 16 and 65 yr were interviewed with the Bradford Somatic Inventory (BSI) and the Hospital Anxiety and Depression Scale (HAD) respectively. The main finding was that the Asian patients reported significantly more somatic and depressive symptoms than the Caucasian patients. Ethnicity was the most important variable determining this result. Keywords: Somatization; Depression; Anxiety; Ethnicity.
INTRODUCTION Patients with persistent somatic symptoms which have no accompanying pathological findings pose diagnostic and therapeutic problems for health care professionals. The term somatization, which is used to describe this phenomenon, has been defined as the "expression of personal and social distress in an idiom of bodily complaints" in association with medical health-seeking behaviour [1]. There are several studies which report that emotional distress is expressed in somatic terms in developing countries [1-6] and furthermore, that this is in contrast to patients from the Western world who are able to communicate their distress in psychological terms [7, 8]. There are studies, on minority ethnic groups who derive from the developing world but who live within the Western world, which report that these groups are also more likely to present with somatic rather than psychological symptoms in the primary care setting [9, 10]. These findings have led to various explanations including the claim that contemporary non-Western cultures not only lack words for anxiety and depression, but also that individuals in these cultures experience emotions in an undifferentiated way [8, 11]. This explanation must be treated with caution. There is a growing literature demonstrating that in the U.S.A. and U.K. at least half of all patients in the primary care setting with a diagnosable psychiatric disorder present with somatic rather than psychological symptoms [12, 13]. This suggests that somatization is not restricted to individuals from non-Western cultures. The other possible explanation is that there are individuals who, irrespective of their cultural origins, have no words * Author to whom correspondence should be addressed at: Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2QZ, U.K. 883
884
S. FAROOQ et al.
for feelings. The term alexithymia is used to describe this phenomenon [14]. The validity of this concept is also in doubt [15]. There are a number of methodological difficulties associated with cross-cultural comparisons. Most notably, research instruments which are developed in one culture and applied to another culture need to be properly validated. This process means much more than back-translations of research instruments into target languages. This point is well illustrated by Krause's [16] comment: "In the course of administering GHQ, I have been asking Punjabis settled in Britain if they feel there is hope in life, and the answers I have received range from somewhat defensive laughter about the stupidity of the question, because 'it is not for us to have hope', . . .". It may be that a number of symptoms are not endorsed, not because the patients are symptomfree in that area, but that the "language used is not such in terms of which these patients feel or think" [17]. The general aim of the present study was to investigate the comparative rates of somatic complaints in a primary care setting between a sample of Asian patients resident in Britain and a sample of indigenous Caucasian British patients. The secondary aims were to delineate the relationship between somatic complaints and emotional disorder and to characterize the factors associated with increased rates of somatization.
METHODS A sample of 195 patients drawn from two general practice surgeries, and aged between 16 and 65 years, were interviewed over a 4-wk period in 1993. Consecutive attenders at the surgeries over the study period were approached to participate in the study and the sample was made up of those who agreed to complete the questionnaires. In order to reduce any systematic bias patients attending either morning or evening clinics respectively were eligible for inclusion in the study. This strategy was employed because it was recognized that the morning clinics were favoured by mothers and children whereas the evening clinics had a larger proportion of men. One surgery was located in an inner city electoral ward and the practice list was made up, predominantly, of patients who originated from India and Pakistan. The other surgery was located in an outer city electoral ward and the practice list was made up, predominantly, of patients who were native Caucasian British. Two interviewers (SF & JS) interviewed all the Asian patients whose interviews were administered in Asian languages. The Bradford Somatic Inventory (BSI) and Hospital Anxiety and Depression Scale (HADs) were administered to the subjects. The BSI was constructed simultaneously in Urdu and English and has been validated in field studies conducted in Pakistan [18, 19]. The HAD was designed for use in medical outpatient clinics [20] and has been translated into Urdu and found to be reliable and valid [21]. The HAD was used in this study because the items in it are constructed from psychological rather than somatic complaints. This is desirable in a study investigating the relationship between psychological and somatic complaints. Both instruments are self-completed questionnaires, but were read out to subjects who were illiterate. This procedure safeguarded against a systematic bias of excluding illiterate subjects from the potential research population. Data, including demographic details, place of birth, and education, occupation and employment status were also gathered. In this study Asian was defined as people originating from India, Pakistan, and Bangladesh irrespective of place of birth.
RESULTS
One hundred and ninety-five patients participated in the study. There was 108 (55.4%) Caucasian patients and 87 (44.6%) Asian patients. Only 16 (18.4%) of the Asian subjects were born in the U.K. The majority (61%) were born in Pakistan, 16 (18.4%) were born in the U.K., 6 (8.4%) in India, 8 (11.2%) in Bangladesh, 4 (5.6%) in Africa, 1 (1.4%) in Ireland; whereas the majority of the Caucasian patients (104;
885
Somatization: A transcultural study Table l.--Study group characteristics Variable
Born in U.K. Mean age (yr) No. male subjects No. unemployed No. married No. illiterate
Asian (n = 87) 16 33.8 46 27 66 21
(18.4%) (SD 15,6) (52.9%) (32.2%) (75.9%) (24.1%)
Caucasian (n = 108)
Statistic
p value
104 (96.2%) 41.8 (SD 14.6) 35 (32.4%) 8 (7.4%) 73 (67.6%) 0 (0%)
X2 = 123.6 (dfl) t = 3.66 (df178) X2= 8.31 (dfl) X2 - 18.63 (dfl) X- = 5.61 (dfl) Z2 = 32.98 (dfl)
<0.001 <0.001 <0.004 <0.001 0.2 <0.001
96.2%) were born in the U.K. The mean age of the Asian subjects was 33.8 yr (SD 15.6) and the mean age of the Caucasian subjects was 41.8 yr (SD 14.6). The Asian sample had significantly more male patients and the proportion of unemployed individuals was significantly greater in this group. Twenty-one (24%) Asian subjects were illiterate whereas none of the Caucasian patients was illiterate. There was no significant difference in the marital status of patients from both ethnic groups. (Table I). The mean BSI score was significantly higher in the Asian subjects. The mean score on the depression subscale of H A D was also significantly higher in the Asian subjects whereas the mean score on the anxiety subscale of H A D was no different between the groups (Table II). Twenty-six (29.9%) Asian subjects were "cases" if a cut-off point of greater than 10 on H A D anxiety subscale was the criterion for "caseness" compared to 30 (27.8%) Caucasian subjects. This finding was not significantly different. With respect to the H A D depression subscale, using a cut-off score of greater than 10, there were 14 (16%) Asian subjects meeting the criterion for "caseness" and 5 (4.6%) Caucasian patients. This difference was statistically significant (Chi-square = 7.20; p = 0.007). As a group the unemployed subjects had a mean H A D depression subscale score of 6.68 (SD 4.16) compared to 4.67 (3.69) in the employed. This difference was significantly higher (t = 8.09; p = 0.005), whereas no statistical differences were observed in the scores on H A D anxiety subscale and BSI respectively between the groups. There were no significant associations between gender and scores on any of the scales. Multiple regression of the total BSI score was carried out taking ethnicity, education and employment as the independent variables. This showed that ethnicity had the
Table II. Variable Mean Total HAD-Anx (SD) Mean Total H A D - D e p (SD) Mean Total BSI (SD)
Mean scores on HADS & BSI
Asian
Caucasian
Statistic
p value
7.43 (5.11 )
8.14 (4.25)
t - 1.04 (df166)
0.3
5.99 (4.15)
4.22 (3.37)
t - 3.21 (df164)
0.002
19.5 (16.0)
15.6 (11.2)
t = 1.95 (dfl48)
0.05
886
S. FAROOQ et al. Table III.--Correlations between scores on HADS & BSI Ethnicity Asian Caucasian
HAD-Anx/BSI r(CI) 0.72 (0.6
HAD-Dep/BSI r(CI) 0.53 (0.36
strongest correlation (Beta - 0.11; p = 0.16) compared to education (Beta 0.019; p = 0.7) or employment (Beta -0.06; p = 0.4). The same analysis was carried out for the depression subscale of HAD. Ethnicity was shown to have the strongest correlation (Beta -0.17; p -- 0.02) compared to education (Beta -0.08; p = 0.3) or employment (Beta -0.09; p = 0.2). In the Asian patients the correlation coefficient between scores on BSI and HAD anxiety subscale was 0.72 and between scores on BSI and HAD depression subscale was 0.53. In the Caucasian group the correlations were 0.48 and 0.53 respectively (Table III). In the Asian sample, the correlation coefficient of the subscales of HAD was 0.60 (CI 0.46
Somatization as measured by the BSI is a common phenomenon in primary care, and Asian patients report more of these somatic symptoms than Caucasian patients. Multiple regression, showed that ethnicity was the most important variable associated with higher scores on the BSI. In addition, the Asian patients reported significantly more depressive symptoms and there were significantly more "cases" of depression compared to Caucasian patients. It was notable that it was anxiety scores which were most correlated with the frequency of somatic complaints. There are other studies, which like ours, report increased rates of somatic complaints in Asian patients in primary care settings [10, 22]. These studies also showed that the somatic complaints were accompanied by psychological complaints, and in one study that there was a linear relationship between somatic complaints and anxiety and depressive complaints respectively [10]. This was replicated in our finding of positive correlations between BSI scores and H A D depression and anxiety subscale scores respectively. It is important to emphasize, though, that it was anxiety scores which were most strongly correlated to somatic complaints. These linear relationships suggests that somatic complaints should be regarded as parallel and equally valid expressions of distress, rather than as a defence against the awareness of affect [15]. We also found that the correlation coefficients between the anxiety and depression subscales of H A D were not dissimilar between the two ethnic groups. This finding undermines Left's hypothesis [11] of emotional undifterentiation in non-Western peoples. Some of our findings, notably the increased rates of depression "cases" in the Asian sample are at variance with some previous reports [23]. The earlier reports of lower rates of emotional disorders among patients of Indian and Pakistan origin were derived from hospital admission figures [24, 25]. The validity of these reports
Somatization: A transcultural study
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is necessarily limited by their reliance upon admissions rates as markers of morbidity levels within populations. It has been suggested that age, gender, social class, and education may contribute to the determination of somatization [26], and also that unemployment may have an influence upon psychosomatic symptoms [27]. In our study, gender, age and employment status did not appear to be particularly related to frequency of somatic complaints whereas ethnicity appeared to be the most important determinant of somatic complaints. The sociodemographic differences between the Asian and Caucasian subjects in our study probably reflect the social and economic characteristics of the immigrant population from the Indian subcontinent. The low proportion of female patients presenting in general practice surgeries is well recognized [24, 28] and suggests either that there is a reluctance on the part of Asian females to attend surgeries or that there is a genuine difference in the levels of morbidity between males and females in this population. In other words that women do not present at surgeries because they are more robust and healthier than their male counterparts. We do not believe that the latter explanation is likely to be correct. The determinants of this relative absence of Asian female patients at primary care centres deserve further study. The disproportionately high levels of unemployment in the Asian sample confirms the widely held view that individuals from immigrant populations suffer social disadvantage, such as unemployment, much more than indigenous populations. Our study suggests that there may be demonstrable emotional burden, in the form of depression, associated with this social disadvantage. This relationship between unemployment and depression has been noted in previous studies [27]. There are obvious methodological problems with our study. We acknowledge that objective data about the patients' physical health were unavailable and that therefore, the relationship between somatic complaints and genuine physical diseases is unknown. However, it is recognized that a thorough physical assessment often cannot unequivocally aid the assignation of somatic complaints to either physical or psychological disorder [26]. On the basis of our study, it appears that there is a modest difference in the frequency of somatic symptoms expressed between the two ethnic groups investigated. However, these differences seem to be less pervasive than is generally thought to be the case. The somatic complaints are related both to depressive and anxiety symptoms. The challenge to health professionals is to understand the complex interplay of factors which determine how one individual will express his distress. If our findings are confirmed, it would also appear that there is considerable psychiatric morbidity in the Asian population which is obscured by hospital admission data. Whilst it has been suggested that doctors may need to change the patient's attributions for optimal management of somatization [13], it seems to us that the aim should also be to change the doctor's attribution of what a patient presents with, rather than simply to encourage the patient to present with what the physician thinks he ought to present with. Acknowledgements We acknowledge the co-operation of our general practice colleagues Drs Houghton, Rumsey, Singhal, Young and Shah who gave us access to their surgeries and patients.
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S. FAROOQ et al. REFERENCES
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