Somatic presentations of distress in China

Abstract

Objective:

Somatic presentations of distress are common cross-culturally and are thought to predominate in Asian cultures such as that of China. From an etic perspective, researchers utilizing empirically validated standardized assessment measures find that somatic symptoms are no more common in individuals of Chinese descent than they are in individuals of European descent. In contrast, patient presentations are heavily influenced by culture and are associated with patterns of illness behavior. The objective of the current review is to determine the culture-specific factors contributing to somatic presentations and descriptions of distress in China.

Method:

The current review was based on a literature search of PubMed and PsychInfo using the terms ‘China,’ ‘Asia,’ ‘somatoform,’ ‘somatization,’ and ‘psychogenic.’

Results:

Factors contributing to somatic presentations of distress in China include stigma and help-seeking behavior, and assessment approaches that ignore culture-specific patterns of symptom reporting, fail to incorporate somatic metaphor and Chinese conceptualizations of distress that emphasize bodily sensation, and ignore the role that culture-specific normative data and culture specific response patterns may produce on assessment results.

Conclusions:

From an emic perspective, there are numerous factors contributing to the appearance of a predominantly somatic presentation of distress in China. Implications for clinical practice are discussed.

Introduction

Somatic presentations of psychological distress predominate in samples of anxious and depressed patients. Somatic presentations of distress can be differentiated from clinically significant symptoms of somatization without co-occurring anxious and affective symptoms, and from clinically significant levels of somatic preoccupation or illness worry (Kirmayer and Robbins, 1991). While somatic presentations of distress are universal (Stewart et al., 1998; Sugahara et al., 2004), they are also heavily influenced by culture. An oft-reported finding is that in individuals of Asian descent, psychological distress is more likely to be manifested somatically when compared to individuals of European descent, an area of study that has received perhaps the greatest attention in China (Draguns, 1996). In this area of study, an understanding of an etic versus emic perspective is crucial, given that the rate and nature of somatic symptoms objectively defined by mental health professionals may be comparable cross-culturally, while subjective somatic complaints are more specific to culture and are associated with patterns of illness behaviour. Factors contributing to culture-specific patterns of somatic symptom reporting and symptom description in China are reviewed. Implications for clinical practice are discussed.

Literature review

The terms ‘China’, ‘Asia’, ‘somatoform’, ‘somatization’, and ‘psychogenic’, were entered into a literature search using PubMed and PsychInfo to collect English-language articles published between 1990–2011. Articles were retained when they contained an investigation of factors contributing to somatic presentations of distress both within China and in Asia at large and cross-culturally. An initial total of 476 articles was reviewed, and using the criterion established for this review, 35 articles were retained.

Factors contributing to symptom presentation and diagnosis

Depression

Somatic presentations of distress are common in mood disorders. Depression is a disorder whose cultural acceptance varies greatly in China, and the prevalence of depression is often reported to be far lower in China than it is elsewhere (Chen et al., 1993; Lu et al., 2008). As a result, the seemingly higher rates of somatic presentations of distress in China were attributed by some to an inverse relationship with the prevalence of depression. However, this was never an accurate conceptualization. Even in the study by Kleinman (1982), in which 100 psychiatric patients initially diagnosed with neurasthenia because of chiefly somatic complaints, were mostly reclassified with depressive or anxiety disorders after a thorough assessment, all of the patients nonetheless had psychological symptoms. There is increasing evidence that rates of depression are actually comparable amongst individuals of Chinese and European descent (Parker et al., 2001a) and cross-cultural studies find that somatic presentations of depression are universal (Simon et al., 1999). In a community survey in Taiwan, rates of somatic presentations of distress in neurotic patients were comparable to those established elsewhere (Cheng, 1989). Interestingly, cross-cultural comparisons can even reveal strong similarities in the nature of specific somatic complaints despite widely disparate backgrounds and geographic locales (Eriksen et al., 2004). It is not culture that is always the overriding variable in predicting a somatic presentation of distress, but other factors, such as the lack of an ongoing relationship between a patient and a physician (Gureje, 2004). Furthermore, in clinical practice, the main complaints of treatment-seeking patients interpreted by psychiatrists as indicative of significant depression are somatic, regardless of culture (Gureje, 2004).

Patient-related variables

Several reports have found that psychological distress is more likely to be manifested somatically in China (Cheung, 1984; Parker et al., 2001a; Ryder et al., 2008). However, the distinction between subjective reporting of discomfort by a patient and the more objective description of symptoms by a clinician is crucial. When standardized diagnostic techniques are utilized, somatic presentations of distress are no more common in areas populated by individuals of Chinese descent than they are in other cultures (Cheng, 1989). In fact, with such methodology, somatic presentations of distress may be less salient than psychological complaints (Yen et al., 2000).

It is suggested that the reporting of somatic symptoms may be a function of a help seeking style (Parker et al., 2005). In rural areas of China there is often no psychiatric care available (Shen et al., 1998), and thus the reporting of psychological symptoms would serve no benefit. Even in urban areas of China where there is greater acceptance of the entity of depression as a diagnosis (Lee and Kleinman, 2007), epidemiological studies still indicate that the overwhelming majority of individuals with any DSM disorder receive no treatment (Shen et al., 2006). Thus, somatic symptom reporting appears a function of illness behaviour. Many other illness behaviours relatively unique to China may contribute to somatic presentations of distress. Studies in China suggest that somatic symptoms are considered appropriate to communicate to healthcare professionals, while psychological symptoms are thought best kept within the family (Cheung, 1984). These findings point to the importance of stigma and related concepts like ‘face’ in collectivistic Asian societies such as China, where verbal/non-verbal manifestations of common mental disorders may compromise the respect accorded an individual by others. It has been argued that interdependent individuals in collectivistic societies express distress via bodily complaints in order to maintain social connections; in contrast, in individualistic societies, somatic presentations of distress may be dysfunctional because they conflict with the value given to direct expression of individual feeling (Kleinman and Kleinman, 1985). Thus, while stigma against mental illness is strong in most societies in the world, it is perhaps even more so in Asian societies such as China (Parker et al., 2001b), where mental illness may be viewed as a weakness in character, a moral defect, or a result of poor family upbringing.

Socialization and child-rearing practices may also contribute to somatic symptom reporting in Asian cultures like China. Individuals of Asian descent are less likely than those of European descent to report having had parents who verbalized positive emotions and displayed physical affection (Lee et al., 2002). Such differences in child rearing may lead to difficulties identifying or expressing emotions (i.e., alexithymia). There appears to be a connection between alexithymia and somatization (Taylor et al., 1992) and some studies show higher mean levels of alexithymia in individuals of Chinese descent compared to individuals of European descent (Dion, 1996; Le et al., 2002; Ryder et al., 2008). The constituent components of alexithymia hold some promise in understanding cross-cultural differences in somatic presentations of distress. In a sample of Chinese and Euro-Canadian participants, Ryder and colleagues (2008) generally found comparable somatic and psychological symptom scale scores regardless of the assessment method employed. However, the relationship between culture and somatic symptom presentation was mediated by a tendency towards externally oriented thinking, rather than difficulty in identifying emotions or describing them to others. Thus, a non-pathological interpretation of the findings suggests that in individuals from China, there is simply less focus on internal states and not necessarily a deficit in the ability to do so. Further, with increased time spent in residence in North American and European cultures, both clinical and non-clinical groups of Chinese-Americans utilize more psychological terms relative to somatic terms when expressing themselves (Chen et al., 2003; Tsai et al., 2004). Greater familiarity with terms of emotional expression used in the USA and Europe is also associated with greater understanding of such concepts on Chinese translations of self-report measures (Cheng, 1989).

Assessment-related variables

Assessment procedure variables moderate the likelihood of somatic symptom reporting in China. One important variable is the technique used to query for symptoms. Careful questioning of Chinese patients better elicits psychological symptoms than does open-ended self-descriptions, which can yield an overwhelmingly somatic picture (Shen et al., 2006) that is likely reflective of illness behaviour. Individuals of Asian descent do not necessarily limit or exclude psychological symptom reporting when discussing distress, but simply do not give these symptoms the salience that they give to their somatic symptoms (Karasz et al., 2007) and may only mention psychological distress at the end of an interview, after somatic symptoms have already been reported (Karasz et al., 2007). These findings reflect the tenets of more traditional Chinese medicinal approaches to disease, which do not contain a symptom hierarchy operationally defining one or two symptoms as pathognomonic, while viewing others as less specific and operational.

Psycholinguistic equivalence is another crucial factor when examining somatic presentations of distress cross-culturally. Assessment techniques that do not consider the numerous and subtle ways in which language interacts with symptom presentation may distort the interpretation of assessment results. Culture-specific idioms of distress are often used in China to describe emotional states (Tung, 1994). Phrases commonly used by Asian-Americans to describe their emotional state include, ‘stress’, ‘nervous’, ‘tired’, ‘poor sleep’, and ‘poor appetite’ (Chen et al., 2002). The link between somatic metaphor and emotional state can be observed in some bilingual Chinese-Americans even when they are expressing themselves in English (Tsai et al., 2004) and can even be extended to the system of written characters (namely those pertaining to the heart) (Lee et al., 2007). Ethnographic interviews with patients with depression in China led Lee, Kleinman, and Kleinman to conclude that some such expressions were not mere idioms of distress, but rather representative of an ‘existential core of depression’ that was ‘bodily’ in nature (Lee et al., 2007, p.5). In this survey, symptoms typical to Western definitions (e.g. loss of interest/drive, hopelessness) were uncovered, but numerous other ‘indigenous experiences and expressions’ (p. 3), primarily combining psychological and bodily experiences such as xinhuang (heart panic), were also recorded.

In China as elsewhere, standardized assessment procedures are not necessarily part and parcel of clinical practice. For instance, changes in the view of somatic presentations of distress over time and the pressure to adhere to a more Western conceptualization of mental illness have created differences in nosology across clinical specialties and geographic regions in China. General practitioners in China, particularly those outside of urban areas, still utilize the term neurasthenia, whereas psychiatrists in urban settings in China have ceased to use the neurasthenia label out of a fear of appearing outdated, preferentially using DSM affective disorder diagnoses instead (Lee and Kleinman, 2007). There is also evidence that clinicians are simply more attuned to physical complaints when working with clients of Asian descent regardless of their own cultural background (Odell et al., 1997). Thus, it is not just the assessment techniques that affect the interpretation of clinical data, but also the assessors themselves. Additionally, on some of the most commonly used methods of assessment in clinical practice, there are considerable differences in response styles across cultures. Respondents in China, in comparison to those in the USA, respond differently to self-report measures, skipping more items, and responding more to midpoints than extremes on items querying positive emotions (Lee et al., 2002). On the MMPI-2 (Butcher et al., 1989), non-clinical Chinese respondents produce higher elevations on most clinical and content scales, including those assessing depression and somatic symptoms (e.g. scales 1, 2, 3, HEA, and DEP) (Cheung et al., 2003) leading to the publication of adjusted norms (Cheung et al., 2003).

Conclusions

Overly broad generalizations concerning the somatization of distress in China are inaccurate and ineffective in explaining current trends. With well-controlled ascertainment methods, rates of somatic symptom reporting may be quite comparable across cultures. There is no definitive evidence that differences in somatic presentations of distress between China and other cultures are associated with the prevalence of depression, given that some well-controlled studies in China and elsewhere have not found great difference in the prevalence of depression or the rate and severity of somatic presentations of distress in depression. From an emic perspective, somatic complaints may differ between China and other cultures due to various illness behaviours, including the lack of acceptance of psychological symptom reporting associated with stigma and the concerns over service provision resulting from purely psychological symptom reporting. These behaviours may potentially reflect the effects of socialization patterns in China that discourage an emphasis on psychological factors. In clinical practice, patients may appear to emphasize somatic symptoms when assessment techniques do not include direct questioning of mood, fail to understand somatic metaphor or Chinese conceptualizations of distress that incorporate the body, and/or do not utilize culture-specific normative data and consideration of response patterns on self-report measures.

The current knowledge base has implications for clinical practice with individuals in China or with individuals of Chinese descent. Cross-cultural portability of psychiatric theory is being replaced by a multifaceted perception of culture in which both local and global context of knowledge are examined (Kirmayer, 2006). Clearly, normative data specific to China needs to be utilized during psychological assessment. Furthermore, in some instances, the use of emic assessment measures may need to supplement measures used cross-culturally, in order to account for idioms of distress, differences in communication styles, and the mind/body dualism that is often manifested in approaches to assessment in North America and Europe but may not be as pronounced in areas of Asia like China. Also important to consider are a patient’s belief system regarding psychiatric care, their level of acculturation to Chinese culture and to that of North America and Europe, and the degree of collectivistic versus individualistic self-construal possessed.