A major goal in this article is to convey that the repertoire of traditions, belief systems, expectations and attitudes we call culture profoundly influences the formation, presentation and management of dissociative and somatoform symptoms. As Kleinman (1987) has articulated with eloquence, "Culture not only shapes illness, but also determines the ways one conceives of illness." Even in similar countries such as those of the western hemisphere (Europe and North America), dramatic differences can be documented in areas such as the way patients present, how medical tests are interpreted, and type and formulation of treatments provided (Payer, 1990). It is therefore expected that even deeper differences may exist for Africans, Asians and Latin Americans that persist following migration.
Because symptoms of dissociation and somatization often follow exposure to traumatic events and may coexist in the same individual (Saxe et al., 1994), it is likely that these syndromes share similar origins and pathophysiological mechanisms. Dissociation and somatization are perhaps the most commonly described sequelae of psychological trauma, and their presence augurs posttraumatic stress disorder and other major psychiatric disorders (Andreski et al., 1998).
Hysteria and hypochondria, the forerunners of the DSM-IV's somatoform disorders, had a distinguished tradition in psychopathology, joining mania and melancholia as psychiatry's four classic syndromes (Foucault, 1961). Medically unexplained somatic presentations have been documented throughout the years, baffling the medical establishment and metamorphosing as medicine changed paradigms (Shorter, 1997, 1994). It has been argued that the concept of somatization may have arisen from the Cartesian dualism prevalent in Western societies, a dichotomy that also led to the cleavage of mental health care from "medical care" (Fabrega, 1991). Individuals affected with somatization display a tendency to amplify physical sensations and endorse multiple physical symptoms involving various body areas that leads to health care seeking. These patients show a tendency to over-report not only physical symptoms, but also psychiatric symptoms when prompted, hence the high levels of psychiatric comorbidity that has been documented for them. Besides over-reporting symptoms, these patients also seem to over-report negative experiences such as adverse life events, sexual abuse and other misfortunes (Morrison, 1989).
Among somatization symptoms, the pseudoneurologic (fainting, fits, paralysis, lump in throat, deafness, blindness, paresthesias and several other presentations that mimic neurological disease) constitute the largest and most distinctive set, and they reliably provide psychopathological imprimatur to the syndromes. These symptoms are all implicit in the notion of conversion and the old concept of hysteria. They are also frequent correlates of trauma and dissociation, predictably appearing in response to stressful events or psychological conflict (Escobar, 1995).
Transcultural aspects. A well-accepted tenet in cross-cultural psychiatry is that the transformation of personal or social distress into somatic complaints is the norm in most cultures (Kleinman, 1987). According to Shorter (1994), the cultural influx on symptom presentation follows socially correct models of proper behavior in the various societies and the prevailing medical paradigms. Thus, patients tend to develop symptoms that are "medically correct," that is, symptoms that physicians expect and understand. Because somatizing individuals are relatively easy to characterize, they provide a useful construct for international comparison. For example, somatic symptoms are easier to recognize and their scrutiny proves less intrusive than that of psychological constructs. Thus, they can be reliably elicited with little resistance offered by the subject because they tend to be less stigmatizing than psychological symptoms.
Some of the large-scale epidemiological surveys, such as those using the Diagnostic Interview Schedule (DIS) or the Composite International Diagnostic Interview (CIDI), have included detailed lists of somatic symptoms. Worldwide, the most common medically unexplained symptoms appear to be gastrointestinal complaints and abnormal skin sensations (World Health Organization, 1992). The Epidemiologic Catchment Area study revealed that the most common medically unexplained somatic symptoms in the United States were gynecological complaints, followed by gastrointestinal and cardiovascular symptoms (Escobar et al., 1987). A number of U.S. studies have documented higher levels of somatization among Latinos, particularly Puerto Rican respondents both in Puerto Rico and on the mainland (Canino et al., 1992; Escobar, 1995; Escobar et al., 1992, 1987).
An international study reported frequent somatic presentations in primary care worldwide, with patients at the Latin-American sites reporting the highest number of somatization symptoms (Gureje et al., 1997). In a primary care study of a multiethnic sample in the United States, we found that Central-American immigrants had significantly higher rates of somatization than other ethnic groups (Escobar et al., 1998) and that war exposure was the single most significant predictor of medically unexplained somatic symptoms in these patients (Holman et al., 1996). Interestingly, in that study we also found that recent immigrants had lower rates of PTSD than U.S.-born patients despite the immigrant patients' higher trauma exposure. This resilience of recent Latino immigrants has been well documented for Mexican-Americans and extends to several other health and mental health dimensions (Escobar, 1998). Cross-cultural studies of depressed patients have documented higher levels of somatic complaints among depressed psychiatric patients in Asia (Kleinman, 1982) and Latin America (Escobar et al., 1983) compared to depressed patients in the United States.
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