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The presentations of psychosocial distress and cultural conflicts are often bodily symptoms, especially in traditional societies and village backgrounds. These might not meet the criteria of the current psychiatric diagnostic systems. Sociocultural milieu contributes to the unique presentations of the stress in the form of idioms of distress. The latter are alternative modes of expressing distress and indicate manifestations of distress in relation to personal and cultural meaning. Health professionals often consider these as hysterical, functional or having functional overlays, and abnormal illness behaviors. Management of idioms of distress would need cultural competence and sensitivity. This article highlights the common idioms of distress in India with specific focus on bodily symptoms.
“It is much more important to know what sort of a patient has a disease, than what sort of disease a patient has.”–William Osler
Across cultures and societies, stress presents in different forms, and the above famous quotation by Osler exemplifies that. Many times these are unique in their presentations to a particular sociocultural milieu, a traditional society, or rural backgrounds. These presentations do not fulfill all the criteria laid down by the current diagnostic systems. These present as medically unexplained symptoms, which are termed as “vague” by the health professionals, but these are in no way vague for the person suffering from these symptoms.
These have been termed differently in literature in a number of ways – folk illnesses/lay illnesses/folk medicine, popular hidden illnesses, idioms of distress, a cry for help, and as ethnomedical complaints and illnesses. When these are described as ethnomedical complaints, specific ethnophysiology and ethnopathology are proposed for them.
This exploratory narrative review will focus on the description of the above concepts and examine the cultural and traditional concomitants of manifestation of stress. This is a narrative review selectively addressing idioms of distress in the Indian subcontinent. Drawing on different culture bound syndromes in the Indian subcontinent, we propose that understanding illness as an idiom of distress might be more productive in terms of cultural sensitivity, clinical compliance, and efficacy of management. Despite many years of research on idioms of distress, clinicians have remained oblivious to its significance leading to poor clinical understanding. This directly affects the rural population, which expresses stress in various forms, which are difficult to comprehend for a city-based physician. The manifestations arise from folk patterns and understanding and present as locally understandable idioms of distress.
Idioms of distress are alternative modes of expressing distress and indicate manifestations of distress in relation to personal and cultural meaning. Distress may arise out of interpersonal conflicts, economic difficulties, and cultural conflicts. These have social implications and are readily accepted by the family and society.
Idioms of distress are perhaps used by those having a weak social support network and limited opportunities to ventilate their feelings and seek help outside the family household. Thus, alternative means of expressing psychosocial distress are utilized. Expression through bodily distress and bodily symptom or somatization is focused upon as an important idiom through which distress is communicated. Idioms of distress are considered as adaptive responses in circumstances where other modes of expression fail to communicate distress adequately or provide appropriate coping strategies. The concept of “cultural idioms of distress” was introduced to draw attention to the fact that reports of bodily distress can serve a communicative function.[1,2,3] A study done in South India on Havik Brahmin women reported the modes of expression as commensality, weight loss, fasting and poisoning, purity, obsession and ambivalence, illness, external forces of disorder such as the evil eye and spirit possession, and devotion.
Popular hidden illness is an ethnomedicine category and is parallel to a professional disease. Popular derives from “popular sector of health-care system” and has a meaning “of the people; of the community,” i.e., recognized in the community but not in professional nosology. “Hidden” as it is not easily detectable, not obvious, and reveals on culturally sensitive exploration. Popular hidden illness focuses on personal experience and understanding of distress from the perspective of the sufferer. It may be understood as an acceptable way of being ill in that society and often help is sought from the traditional healing systems. In this way, idioms of distress, when they become a common mode of presentation, manifest as popular hidden illness.
Folk illnesses are set of several symptoms which cohere in a given community, and the individuals respond in similarly patterned ways. Persons in this community or society understand, diagnose, and heal illness in a traditional or culturally meaningful way – a local context of meaning of the illness. The dissonance caused by different models of illness does impede healing. A meaning-centered approach employing both ethnographic and epidemiological methods is needed. Folk illness is not the same as “folk version” of medical illnesses. It is concerned with the cultural construction of sickness and medicine among lay people, folk healers, and employs folkloric material that may be fruitful guide to the meanings which sickness has for those experiencing and treating it.
Concepts of idioms of distress, folk illness, and popular hidden illness help us to get a complete picture of the suffering and distress, and how the person, family, and society view it. These concepts overlap in their descriptions. Such presentations happen in the medical settings including primary health care in India. More often these symptoms are likely to be construed as medically unexplained or may be treated as “normal” variations or feigning an illness. In today's multicultural society, assuring quality health care for all persons requires that physicians understand how each patient's sociocultural background affects his or her health beliefs and behaviors.
Sociocultural differences, when misunderstood, can adversely affect the cross-cultural physician–patient interaction. Such misunderstandings often reflect a difference in culturally determined values, with effects ranging from mild discomfort to noncooperation to a major lack of trust that disintegrates the therapeutic relationship. At the interface between culturally shaped illness and biomedical disease, there is a significant potential for being lost in translation. These concepts discuss traditional health care in the context of some of the cultural aspects of health beliefs, perceptions, and practices in the different ethnic groups and rural family practices. This helps to promote communication and cooperation between doctors and patients, improves clinical diagnosis and management, avoids cultural blind spots and unnecessary medical testing, and leads to better adherence to treatment by patients.
This view includes traditional practices of “hot and cold,”, notions of Yin-Yang and Ayurveda, cultural healing, alternative medicine, cultural perception of body structures, and cultural practices in the context of health. Modern and traditional medical systems are potentially complementary rather than antagonistic. Ethnic and cultural considerations can be integrated further into the modern health delivery system to improve care and health outcomes. Each culture has certain core beliefs about the body, mind, and soul and also the health. Hence, the Western concepts often may not be applicable directly.
Health professionals often consider these as hysterical, functional or having functional overlays, abnormal illness behaviors or somatic neurosis. The genesis or development of these may be related to sociocultural, traditional, early childhood rearing and development, and experiences. “Medically unexplained symptoms” have acceptable “traditional explanations” or “folk medical explanations.”. Folk medicine has no “unexplained symptoms.” Disparities in the views of medical professionals and laypersons are the cause of distress, poor compliance, chronicity, and abnormal illness behavior.
The common presentations to a health setting are often physical or bodily symptoms which could be an idiom of distress. There are hardly any epidemiological studies on the prevalence of these folk illnesses or idioms of distress in Indian rural settings. Most studies have been qualitative to understand the evolution and presentation of the symptom. A recent study conducted on 301 patients who attended the Psychiatry Outpatient Services, NIMHANS, Bengaluru, India, with bodily symptom as presenting symptoms and were assessed for nature and frequency of bodily symptoms. Even though headache and pain in extremities were the most commonly described symptoms, whole body ache was also reported quite often. Patients who were diagnosed to have somatoform disorders reported the following symptoms which did not fit into any particular category: Nerves beating, pulling sensation, numbness, reeling sensation, pulsating sensation in the head, buzzing head, heaviness of head, Jhum-Jhum sensation, burning sensation in head and other parts of the body, half body pain/pain in left half/right half of the body, heat and cold sensations, bowel evacuation/constipation, palpitation/breathing difficulty, worms crawling sensation, and left cornea pain/redness of eyes. These participants were diagnosed to have anxiety, depression, and stress-related disorders. This confirmed our intuition that idioms of distress continue to exist in the present times, and hence there is a need for fresh relook at these concepts.
Research conducted in India on the idioms of distress, namely, Dhat syndrome,[8,9,10] female Dhat syndrome,[1,3,11] and sinking heart syndrome (Krause 1989). Dhat syndrome is characterized by feelings of weakness of body and mind and attributed to loss of semen through night falls and masturbation and leads to significant distress to the individual.[8,9,10] “Idiom of distress,” in the form of leukorrhea (white discharge per vagina) as a symptom state associated with a complex of cultural meanings as well as multiple etiologies. Prevalent etiological notions of leukorrhea include a dissolving of bones, loss of Dhatu (vital fluid), and overheat.[1,10] Leukorrhea may represent a culturally shaped “bodily idiom of distress,” in which concerns about loss of genital secretions reflect wider issues of social stress. Problems may arise when a symptom with deep cultural meaning is interpreted in a purely biomedical framework.
“Sinking heart” is an illness, in which physical sensations in the heart or in the chest are experienced, and these symptoms are thought to be caused by excessive heat, exhaustion, worry, and/or social failure. The Punjabi model of “sinking heart” offers a culture-bound explanation of somatic symptoms. It is based on culturally specific ideas about the person, the self, and the heart and on the assumption that physical, emotional, and social symptoms of pathology accompany each other. The Punjabi model of sinking heart does not exactly correspond to medical models of heart distress. The sinking heart model bears closest resemblance to a Western model of stress. The similarity between these two models is in the form rather than in the content.
Jhum-Jhum syndrome is observed in medical practice in Nepal, North India, and the hilly regions of Garhwal. It presents with sensory symptoms, mainly tingling numbness, and without any neurological deficits. There are no obvious social or psychological stresses. It is a form of expressing distress, dissatisfaction, and displeasure in the community and considered as an acceptable form of illness quite commonly and serves an adaptive role.
Somatic neurosis was described in women presenting with multiple somatic complaints, mainly, aches and pains, fatigue, and tiredness and seen commonly in Muslim women and later, studied and noted in Hindu women as well. There were no obvious psychosocial stresses, rather they had impoverished, restrictive, social environment, where complaining of somatic symptoms was acceptable, without any stigma. It was subsequently confirmed in the community studies.[17,18]
The above descriptions indicate that certain somatic symptoms serve as cultural idioms of distress in many ethnocultural groups and if misinterpreted by the clinician, may lead to unnecessary diagnostic procedures or inappropriate treatment. Clinicians must learn to decode the meaning of somatic and dissociative symptoms, which are not simply indices of disease or disorder but part of a language of distress with interpersonal and wider social meanings. Potential meanings of somatic symptoms include an index of disease or disorder, symbolic expression of intrapsychic conflict, indication of specific psychopathology, idiomatic expression of distress, and a metaphor for experience.
As a culturally available idiom, somatic symptoms express discomfort and distress in ways that are intelligible within the individual's social milieu but may have different meanings to outsiders. Somatic idioms of distress commonly embody combinations of somatic, emotional, and social meanings. Complaints that seem (to the medical practitioner) to be evidence of a syndrome of somatic symptoms may, in reality, encode an ethnomedical theory.
Consequently, a patient's narrative of his or her illness may include a significant subtext, linking his or her physical distress to social predicaments, moral sentiments, and otherwise unexpressed emotions. Certain common ethno-physiological ideas serve to link diverse bodily symptoms and behaviors within a system that has both hygienic and moral dimensions. For example, fatigue, weakness, and chronic pain are common as somatized forms of anxiety and depression in Indian settings.
Management of idioms of distress would need cultural competence and sensitivity. It would be useful to understand the explanatory models held by the individuals and make a cultural formulation. Such explanations and counseling would be more acceptable to the individuals and their families, more so in the rural areas. This would also improve compliance with medications if prescribed.
“A full understanding of the illness belief systems which are available to the layman and to the physician, if coupled with a willingness to negotiate a more functional set of explanatory models, may pave the way to a richer, deeper, and above all more satisfying experience to healing.” This review describes the need to examine health and illness through the lens of idioms of distress. These invariably are the cultural blind spots in clinical practice and practitioners have to be aware of these blind spots. Recognizing idioms of distress helps to establish rapport and build the type of empathic connection that comes from being copresent, engaging in a “somatic mode of attention,” “working within the metaphor,” and paying close attention to metacommunication. The importance of idioms of distress approach to psychiatric evaluation is to be acknowledged. This could avoid health professional's cultural blind spots!! Idioms of distress are intermeshed in the cultural fabric of health and illness, exemplified by the following quote,
“That which enters the mind through reason can be corrected.
That which is admitted through faith, hardly ever!”–Charles de Cafe’
There are no conflicts of interest.