Saturday, March 10, 2012

Essay on Somatoform Disorders

Essay on Somatoform Disorders

Somatoform Disorders and how they differ across cultures
Introduction to somatoform disorders
For centuries, somatoform disorders (ICD-10: F45) have been described through numerous diverse diagnoses. They can be generally divided into general syndromes (e.g., neurasthenia, vegetative dystonia), functional syndromes (difficulties in specific organs such as the heart or breathing systems) and repeated pain, often varying between organs. All of which can be explained by some physical disorder or disease. However, in the case of somatoform disorders, these symptoms appear with no physical evidences, or with repeated medical findings which cannot explain the extent to which the symptoms exist. The patient is preoccupied with the symptoms and repeatedly demands to receive medical attention (WHO, 2006). Somatoform disorders can be related to some psychiatric disorder, although many of these patients are not mentally ill; mental stress, or unpleasant life experiences, however, may bring about such a disorder, as well as need for attention (Minhas and Nizami, 2006; Janca et al, 2006).

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As a consequence, the treatment of such patients is complicated and frustrating for both the patient and the physician (Minhas and Nizami, 2006). The lack of physical (and often mental) evidence to support the symptoms or complaints leads to recurring examinations and referrals. On the other hand, physicians must be careful not to attribute every lack of findings to the disorder, as it might lead to mistreatment of a patient in genuine physical need. Therefore, the WHO (2006) suggests a minimal duration of two years of complaints without findings to support a somatoform disorder diagnosis. A shorter span is defined as undifferentiated somatoform disorder (F45.1) deserves both physical and mental care, in opposed to the other disorders in that group, which calls merely for psychological or psychiatric care. Nonetheless, it is the physician’s responsibility to manage a somatoform disorder as any other disease; those patients must be diagnosed, treated and followed as patients with physical illnesses. Proper research, training and vigilance of the healthcare system is imperative (Abas et al, 2003), and can be very well justified from the economic point of view, as is cheaper to deliver mental care than to occupy the system with continual examinations, procedures and secondary care (see also: Janca et al, 2006).

The disorder is extremely common in medicine and the most common mental illness in non-mental medical institutions (Minhas and Nizami, 2006). Reviewing precedent studies, Minhas and Nizami (2006) noted two studies in which about 30% of the patients in primary care and outpatient clinics were ultimately diagnosed with somatoform disorder. The main complaint was pain. Nevertheless, Janka et al (2006) stress that most of those patients meet only the criteria for sub-threshold diagnoses and warn from the over diagnosis of undifferentiated disorders in primary care settings.

Estimations regarding the disorder’s prevalence rate differ. A rate of about one percent of general population (including comorbidities) can be regarded as a sound estimation (Minhas and Nizami, 2006). However, F45.1 is a much more common diagnosis, due to its short span and lesser demand for reoccurring, varying complaints.

There is some ways to prevent the disorder, or at least patients’ demand for ineffective medical care. Pre-diagnosis and treatment of mental distress through behavioural medicine are the key issues here (Kirmayer et al, 2004).

Prevention probability for undifferentiated somatoform disorders are rather low (Jenka et al, 2006), perhaps since the physical symptoms are the first to signal an emotional distress. On the contrary, prevalence improves dramatically in patients with comorbidity (e.g., diagnosed mental patients) or when the patient is willing to admit a distress on an early stage of the medical intervention (Kirmayer et al, 2004; Wool and Barsky, 2004).

Somatoform disorders in cultural context
Medicine is much more than ICD and DSM criteria. The distinction between “healthy” and “ill” is not merely the existence of some physical or mental diagnosed disorder. A person’s feeling is a key issue here; a carrier of AIDS can feel well and healthy, while a perfectly healthy (in classic medical terms) individual can feel pain or have difficulties to breath. Moreover, some individuals are reluctant to ask for medical advice while others use health services as a source of comfort or entertainment.

The same differences also exist between cultures, socioeconomic conditions, gender and age. In addition, some complaints are more common, or exist only in specific cultures. For example, the daht syndrome, a preoccupation with loss of semen which is typical for Indian males, can be directly linked to the perception of sexual performance in the Indian culture and, interestingly, its traditional medicine (Ranjith and Mohan, 2006).

Additional generator of somatoform disorders, mainly concern with the use of language, is patients’ embarrassment from their own emotional distress. Summarizing findings from the Indian subcontinent, Minhas and Nizami (2006) report that Punjabi women were reluctant to use to word “depression” (which they knew) and used idioms from the ayurvedic culture such as “pressure on the mind” and “feeling of heat”. One study cited by the authors has found significantly higher rates of somatoform disorders among indigenous Asian than indigenous British patients in Pakistani primary care centres. The authors suggest that a lack of abstract vocabulary among non-Western cultures is a cause for describing distress using physical terms such as pain.

Terminology and culture are also a main cause of what seems as somatoform syndromes among immigrants, in particular non-Western immigrants who visit a Western doctor. Here the problem is twofold. First, possible communication problems from the patient’s side may bias the medical interview. Second, the physician’s misunderstanding of a perfectly acceptable clinical picture to describe distress on the patient’s culture. Kirmayer et al (2004) portray the phong tap and uat u'c, two common explanatory idioms in Vietnamese popular health terminology. Phong Tap is used to describe mental distress through feeling of wind and cold. Uat u’c is a bit more complicated concept, trying to relate physical symptoms to situations of social injustice. These can be easy cases of somatoform disorders; however, a Western physician who is not trained in Vietnamese health terms (and presumably primary care practitioners in those communities learn to know these phenomenons) will never be able to treat them properly.

As mentioned earlier, prevalence differs also within a culture, often with accordance to socio-economic and other demographic status. The prevalence of somatoform disorders tends to increase in positive correlation to age. In addition, women, married, widowed, divorced, unemployed and retired people are more likely than others to be diagnosed with some kind of somatoform disorder (Janka et al, 2006). On the other hand, Canino et al (1992) did not find any significant socioeconomic pattern, rather than explained prevalence only on a cultural basis.

Implications on treatment management The WHO guidelines mentioned earlier provide a balance between overtreatment of somatoform patients and a rush diagnosis with a “note to the psychiatrist.” It is clear, though that the definitions (stating exact measurements for diagnosis) are far from covering all the cases. Most of the literature stress training of the medical force as the key success factor. Special attention should be placed to communities at higher risk, such as low socioeconomic groups, elderly people and people with immigration background.

Since somatoform disorders appears in 15%-30% of all medical consultations (Kirmayer et al, 2004), primary care personal must poses the knowledge and the abilities (e.g., in-house emotional consultant, preventive medicine to people at risk) to handle the disorder in the practice. In addition, remembering that socioeconomic and cultural factors Another important step is to reduce the reluctance of asking mental help, especially in traditional cultures, in a way which is similar to birth control and AIDS (sexual education).

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