VOICES IN MY HEAD: Somatization in a Tamil Slum

By Cheruba Prabakar

Diagnosis Please?

Heart beating, forehead sweating, chest pounding, pain spreading, heart-attack coming...STOP! Are you really suffering from a heart attack…or did you just induce one through the powers of your imaginative mind? Perhaps you started feeling this way after that terrible fallout with your significant other, or when you simply could not digest the family drama unfolding in your home. You agonize about your problems day in and day out, wringing them through your mind. You go to your doctor but she declares you free of any medical problems. You are not sure what it is, but your symptoms surprise you once in a while, accompanied by a nervous stomach, dizziness, and some mild back pain. What could it be?

Somatization is the process by which an individual's emotional and mental stress is exhibited via physical symptoms, and one in which no physical or pathological cause is identified upon extensive investigation. We may not actively realize or admit it, but we all somatize at one level or the other. While some of us have the common "jitters" during stressful situations others of us are more seriously afflicted, suffering chronic pain and disability.

While the connection between mind and body is still viewed as "fluffy" or "soft" medicine by some, it is very real and palpable in the lives of many around the world. I was intrigued by this phenomenon last year when I saw Mrs. Adams* in clinic. She complained of sciatic pain and generalized aches in her legs that refused to respond to any form of therapy we offered her. After several weeks of meticulous work up and no concrete findings, she agreed to try and anti-depressant. To my amazement, her condition significantly improved. A more detailed social history later revealed marital tensions with her husband. Not all events in our lives can be twinned like this…but the link is sometimes unmistakable.

Around the world in 60 days

My interest in somatization took me across the globe this summer to a slum in Mumbai, India. Although I was born and spent twelve years of my life in South India, I was a stranger to Mumbai. I knew neither Hindi-the local language-nor the culture in this bollywood city. However, through much groundwork with the help of my professor, I identified a Tamil slum community in which I could work. Tamil is my native language, and I thought it imperative to be able to converse fluently in order to get any significant work accomplished. I was also interested in this particular community for another reason. Preliminary work on somatization had already been carried out on a population of married women in this slum. The analyzed results thus far show a strong correlation between a woman's life stressors and the degree to which she somatized (Schensul et al, unpublished results). My goal was to build on this existing foundation of knowledge by studying somatization in young, unmarried, Tamil women…much like myself.

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I found accommodation in a nearby university dormitory and settled in, ready to begin work. I was welcomed by monsoon rains that flooded the streets and made it impossible to travel anywhere, especially with buses and trains being stranded. Soon after, bomb blasts planted in commuter trains rocked the city, creating chaos everywhere. Amidst the attacks and constant threats to personal safety, I was trying to adjust to the new life, make friends, and get my work underway, all of which proved to be a challenge initially. I was introduced to a couple of key informants in the slum community (Cheetacamp) by some field staff from the university, and I was on my own from there. I spent several hours a day in Cheetacamp, navigating through the community to find young, unmarried, Tamil women who were willing to talk to me about their lives. There was more hesitation on their part than I had originally anticipated. Suspicion and doubt clouded their minds, but soon after realizing I was a fluent Tamil speaker, their tensions eased.

I spent the first two weeks interviewing approximately twenty women, soliciting details about their daily lives. I was most concerned about the family structure and environment in which they lived, their academic pursuits if they could afford it, their romantic lives, and their physical health. Through a series of questions, I tried to glean the status of their emotional and mental health and how it contributed to any somatic illnesses or symptoms that they experienced. During the course of the interview, I also obtained an appropriate medical history to discern whether the women were undergoing other medical problems that might be contributing to their somatic complaints.

Voices in my Head

"My father died, my mother is very sick, and I have to work to support my family," said seventeen-year old Selvi as she tucked a strand of her jet-black hair behind her ear. The skin on her hands were cracking like a mirror into a thousand pieces. It was only mid-morning, but she had been up for several hours already: sweeping, cleaning vessels, washing clothes, storing drinking water, cooking, making chai, and now preparing to go to work. She was a bag worker, and spent 8 hours a day on an assembly line in a factory. She gave me an hour of her time in what seemed like a natural break in her day; probably secretly thankful for a chance to sit down and rest her weary body.

Selvi told me about her life, not with the voice of a victim but that of a survivor. The duty to family-a strongly woven thread into Indian society-inspired her to take on the responsibility of caring for her ailing mother and her 3 younger siblings. She worked hard, constantly under the watchful eye of bothersome relatives, gossiping tongues, and a complete ban on her personal freedom. After all, she was a girl. Selvi did not have the money to go to school, the time to make friends, nor the desire to appease her community regarding the trivial matters they branded her for-like wearing pants to work one day.

She was tired. Her voice was weary and her mind seemed saturated with sorrow. She complained of constant headaches that were "dull and heavy." When she was under extreme stress, she also described periods of "fast heart beats," most likely reflecting heart palpitations. Selvi mentioned having visited a physician once who dismissed her concerns after attributing her problems to a low blood count (without doing a test). She did not talk about her problems and fears to anyone. She was clearly under immense emotional turmoil and when asked if her anxiety and stress could account for her headaches and palpitations, she nodded. Before she left, she touched my arm and said "one more thing sister…I also hear voices in my head."

I have narrated just one encounter with a somatizing patient, but I saw several more throughout my time in Cheetacamp. The living conditions in the slum were such that many of the young women were undergoing tremendous psychological stress. Eight to ten inhabitants in a household was not uncommon, and the home was typically just a single room. The women had no privacy and often felt very restricted in their living space. They woke up early to do household chores, stand in line to store drinking water (that was available only at specific times of the day), pack lunches for younger siblings, go to work if they were employed, attend tailoring classes, and do some cooking in the home. Despite the work they did at home they were often chided for seemingly trivial things like wearing nail polish or speaking with the neighborhood boy. It is thus of no surprise that the young women in this community dealt with a basal level of stress and anxiety at all times.

It is interesting to note how each woman chose to deal with state of psychological turmoil. Some poured their hearts out to friends, some wrote in journals, and others bottled up their problems letting it rise within them as the waves in life grew more turbulent. This final group of women represented the largest group of somatizers, most often presenting with the most severe symptoms. The young women were often overjoyed at having the opportunity to openly discuss their problems with me, quickly inviting me to their homes for a chat over chai. Many of them longed for confidential counseling resources and admitted that they would utilize them if they existed. Currently, no such resources are available, mostly owing to the lack of knowledge about how one's mental health can seep into other areas of life, creating adverse events.

Somatization in the global arena

In discussing my ideas for summer research, I found that many people including medical students were unfamiliar with somatization. Although statistics vary, it is reported that 45 to 75% of patients who present to out patient primary care clinics in the United States and England are somatizers (Feldman, 1997). In a large community survey of 3000 women conducted in Goa, India, chronic fatigue was associated with older age, family debt, lower education, hunger and most significantly with sexual violence by the husband and poor mental health (Patel, et al 2005). Somatizers are often nick named as having the "thick chart syndrome," as their records are filled with meticulous work ups with no conclusive diagnosis. Failure to recognize a somatizing patient is cost-heavy on our health care system in terms of unwanted tests and diagnostic procedures. I realize that recognizing a somatizing patient is an art. While you don't want to see beyond what is present, you also don't want to fail to see that which IS present. As my preceptor told me, this skill of discernment comes with experience.

So how is somatization disorder diagnosed? According to the DSM-IV, To receive a diagnosis of somatization disorder, the individual must have a history of multiple physical complaints that began before age 30 and that continued for several years. These symptoms must cause significant impairment to social, occupational or other areas of functioning-or lead the patient to seek medical treatment. In addition, each of the following four criteria must be met: the individual must report a history of pain affecting at least four different parts or functions of the body, a history of at least two gastrointestinal symptoms must be reported, there must be a history of at least one sexual or reproductive symptom, and one symptom must mimic a neurological condition. If a thorough medical evaluation reveals no evidence of an underlying medical or medication-induced condition, the diagnosis of somatization disorder is likely (DSM IV).

Although the above criteria are outlined in the DSM-IV, not every part of it is followed during diagnosis, both in the U.S. and in India. For example, patients are diagnosed with somatization disorder even if their complaints began much later than 30 years old, if they do not have a symptom from each criteria, and even without thorough medical investigation for all other potential sources of the somatic manifestations. From my experience, I see this as being true both in the U.S and India. Perhaps the diagnosis fits perfectly with the outlined criteria in the DSM-IV, but physicians do not always seek to elicit that information. I suspect it is an intuition that one gains through clinical practice.

Somatization is not a new topic of study in India; it is one of growing interest among many workers in the field of mental health. Previous research on this topic has been conducted and significant results have been found. Studies have shown somatic symptoms manifesting in "Dhat syndrome" or semen loss (Perme, et al, 2005), patients presenting with non cardiac chest pain having a higher rate of mental disorders (Alexander et al, 1994), and a strong correlation between vaginal discharge and somatic symptoms in women (Chaturvedi et al, 1993).

I worked with approximately 80 women this summer, and investigated the effects of three specific domains on the level of somatization: family dynamics, romantic relationships, and perception of gossip about oneself in the community. Preliminary analysis of my data show that the top two stressors in these women's lives were family dynamics (including variables like personal freedom, burden of chores, familial relationships, and treatment by parents in comparison to siblings) (47%) and involvement in romantic relationships (12%). They experienced stress to varying degrees: low (18%), medium (49%), high (33%). Headaches were the biggest indicator of somatization, with a strong correlation between those who described themselves under very high stress and the frequency with which they experienced headaches. Women who were involved in romantic relationships and felt that they were being gossiped about in the community experienced a greater number of somatic symptoms and a higher level of basal stress.

Psychiatry is becoming an increasingly more important and demanding field in medicine, with psychosomatic disorders now a newly declared subspecialty. Content with our technological gadgets and comforts in the Western world, we face the problem of human isolation leading to higher rates of loneliness and depression. Contrary to this situation, the slum in Mumbai was so crowded that privacy was a privilege only to be dreamed of. Amidst this intense will to survive, the young girls that I spoke with faced an incredible amount of emotional and psychological stress often leading to a range of somatic symptoms.

Moving Forward

So what steps are being taken to address somatization in India? The answer probably depends on who you talk to. Psychiatrists in the more urban medical settings are not shy about being truthful with their patients and offering them counseling services or suggesting alternative therapies of stress relief like yoga, spiritual interventions, or meditation. Physicians that I talked with in the slums however, admitted that "telling someone that they were imagining their problems or that their problems were not pathologically real" was not yet an acceptable diagnosis in their community. In extreme cases where patients exhibited severe symptoms like hallucinations and seizures that could perhaps be indicative of more serious mental disorders, they were sent to religious leaders or traditional practioners to be "cleansed." In such cases, the symptoms were not attributed to pathology, but to "evil forces."

Interestingly, I found that for every woman who believed in somatization, there was one who did not. Some even thought that positing such a connection was simply notorious. Currently, there are no interventions in place for educating, assessing, and reducing the sources of stress in these women's lives. My work is the first attempt at establishing a baseline in unmarried women, and hopefully specific interventions for education, assessment and therapy will follow in the future.

Unfortunately, seeing a counselor or psychiatrist is still taboo in Cheetacamp and many other communities in India. Visiting one meant you were "crazy" or "unstable" and you were promptly branded with many undesired labels. However, one cannot dismiss the stigma as something that will magically disappear or eventually be taken care of. Education and activism on behalf of these patients is imperative.

When discussing global health issues, mental health let alone somatization is not among the topics that typically surface. While various groups are on the public front advocating for the issues they are most passionate about, mental health has been left behind. We cannot afford to let it hang in the backdrop, not anymore. May the voices that people hear in their heads signal a need for help and counsel, not apathy, shame or disgrace. After all, as the popular saying goes, "The face is the index of the mind."

Sources:

Alexander, et al "Mental disorders in patients with noncardiac chest pain." Acta Psychiatr Scand. 1994 May;89(5):291-3.

Chaturvedi, et al "Somatization misattributed to non-pathological vaginal discharge." Journal of Psychosomatic Research, 1993 Sep;37(6):575-9.

Diagnostic and Statistical Manual IV

Feldman, M.D and Christensen, J.F, "Behavioral Medicine in Primary Care." McGraw-Hill, 1997.

Patel, et al, "Chronic fatigue in developing countries: population based survey of women in India." BMJ 2005 May 21; 330 (7501): p. 1190.

Perme, et al, "Dhat (semen loss) syndrome: a functional somatic syndrome of the Indian subcontinent?" General Hospital Psychiatry, 2005 May-Jun;27(3):215-7

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