Psychological approaches to somatisation in developing countries

Medically unexplained somatic complaints are among the most common clinical presentations in primary care in developing countries and they are a considerable burden for patients and the healthcare system. They are assumed to be the result of psychosocial factors, and the process by which symptoms are experienced is termed somatisation. Common mental disorders, somatoform disorders and socioeconomic adversities are the major risk factors for these complaints. There is evidence suggesting that cognitive–behavioural therapy, which has proven efficacy for somatoform disorders in the developed world, can be used in developing countries with some adaptations (e.g. by simplifying the content so that it can be applied in primary care by non-specialist health practitioners; using culturally appropriate analogies; and delivering the intervention over fewer and shorter sessions). The main components of such an intervention are presented in this article. Vikram Patel is a reader in international mental health at the London School of Hygiene and Tropical Medicine (NPHIRU, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. e-mail: [email protected]). Athula Sumathipala is an honorary lecturer at the Institute of Psychiatry, London. Both authors are psychiatrists who have been working in South Asia, conducting research into public health aspects of mental disorders, particularly the efficacy and cost-effectiveness of locally available and feasible treatments in primary care, and building research capacity in the region. Both wish to acknowledge the Wellcome Trust for supporting their research on mental disorders in South Asia. Psychological approaches to somatisation 55 Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/ of anxiety. In addition, somatic complaints may be idioms for help-seeking for severe social adversities such as domestic violence. Other reasons for somatisation include the stigma associated with mental illness and the perception (often based on reality) that doctors are more concerned with, and likely to respond to, somatic symptoms. In this article we use the term ‘somatic complaints’ to denote physical complaints that are clearly not attributable to a physical disease, and focus our discussion of management on symptoms associated with somatoform disorders. Somatic complaints in developing countries Clinical presentation There has been limited research on the clinical presentation of somatic symptoms (Chaturvedi et al, 1988; Chaturvedi et al, 1993; Isaac et al, 1995; Janca et al, 1995; Sumathipala et al, 2004) and the prevalence and aetiology of somatic complaints in primary care in developing countries (Gureje et al, 1997). The key finding of these studies is that, despite the enormous variation in the prevalence of various somatic complaints, the overall burden of such complaints is high. Some complaints are universal, being described in developed countries as well. Prominent among these are: fatigue and tiredness; aches and pains, notably headaches and generalised body pains; and abdominal discomfort. Some somatic syndromes, such as the loss of semen syndrome, were once widely recognised in developed societies, but are now largely found only in non-Western cultures (Sumathipala et al, 2004). These historical trends are perhaps best understood in the context of Cartesian dualism, which became a strong influence on Western biomedical concepts in the early 20th century.