Transcultural Aspects of Dissociative and Somatoform Disorders

There are also anecdotal reports suggesting that the type of symptoms presented by somatizing patients may differ in various cultural settings. For example, in Nigeria and India common somatic symptoms are "feeling of heat," "peppery and crawling sensations," "numbness," "burning hands and feet," and "hot, peppery sensations in head"--symptoms that seem extremely rare in Western countries.

Ataque de nervios (attack of nervousness). This acute, drama-laden clinical syndrome that typically follows stressful events has been described in inhabitants of Caribbean countries and in Caribbean immigrants to the United States. It includes clusters of somatization and dissociative symptoms that appear together with rather dramatic behavioral correlates. Ataque seems highly prevalent, with one out of five community respondents interviewed on the island of Puerto Rico reporting having experienced at least one of these episodes during their lifetime (Guarnaccia et al., 1993). While attempts to frame these syndromes into the more conventional mainstream categories may constitute a category fallacy (Kleinman, 1977), studies of patients in New York City indicate that symptoms of ataque are often associated with diagnoses of panic attacks and panic disorder (Lewis-Fernandez et al., 2002). Clinical manifestations of ataque include headache, trembling, heart palpitations, stomach disturbances, a sensation of heat rising to the head, numbness of extremities and, at times, pseudoseizures, fainting or unusual "spells"--all symptoms suggestive of somatization.

Dissociation is a classical phenomenon in psychopathology that has been well studied for many decades. Investigators distinguish pathological from non-pathological forms of dissociation to underline that some individuals may have a unique ability to dissociate under special circumstances; therefore, these are not always symptoms of a mental disorder but may be normative in some cultures. Dissociative phenomena may have strong biologic roots, with genetic influences accounting for about 50% of the variance in twin studies (Jang et al., 1998). Dissociative disorders in the DSM-IV include dissociative amnesia, dissociative fugue, depersonalization disorder and dissociative identity disorder (multiple personality disorder [MPD]). The latter diagnosis is very controversial, with fewer than 40% of U.S. psychiatrists surveyed supporting its inclusion in the nomenclature and less than one-third attesting to its diagnostic validity.

Dissociative disorders cross-culturally. A number of dissociation and possession states have been reported in various countries (Table). These culture-bound syndromes have been viewed by some investigators as variations of the normal startle response. A study in Japan suggested that the clinical features of dissociative disorders among the Japanese are very similar to those reported in North America (Umesue et al., 1996). A study in South Africa suggested that dissociation was rare in blacks and that the syndrome was not clearly related to traumatic experiences such as sexual abuse (Gangdev and Maxwell, 1996). In an Indian study, it was observed that most patients with dissociation presented with a "brief dissociative stupor" that coexisted with anxiety and panic symptoms. No fugue, amnesia, possession or identity disorders were observed (Alexander et al., 1997). Regarding the cross-cultural aspects of MPD, more than 60% of the cases originally reported came from North America (Golub, 1995). Several investigators have suggested that MPD is an iatrogenic disorder largely confined to North America (one of the few culture-bound syndromes in the region), and that it is rare or nonexistent in Great Britain, Sweden, Russia, India and Southeast Asia (Golub, 1995). Moreover, in the United States, MPD is rarely described among Latinos, and it seems to beeven rarer among Asian-Americans. Interestingly, in a study in Canada, 20% of the alternative personalities reported by MPD sufferers belonged to a different race, perhaps reflecting the higher levels of ethnic integration reached in that country.

In this brief review, it has been proposed that somatoform and dissociative syndromes are heterogeneous, incorporating many overlapping features as well as symptoms of several other disorders. These syndromes are at the core of the stress reactive syndromes and appear to be present in all cultures as the most typical sequelae of trauma. Dissociation and somatization phenomena are more frequently reported from non-Western, developing societies and have been generally framed as rather exotic culture-bound syndromes. The only exception is dissociative identity disorder or MPD, a controversial entity that seems endemic to North America. Among the problems faced by this area of research, a key obstacle is the reliance on individual accounts that are largely retrospective and not verifiable with more objective sources. Also, the need to remember events that took place a long time previously places a heavy load on the accuracy of human memory, a faculty that can be rather fragile and impressionable. Future research will need to focus on prospective, longitudinal observations, using several informants and objective sources to verify the information, as well as carefully selected control groups.