Psychosomatic and now called Somatic Symptom Disorders: I am reminded of the young man who lost the tip of one finger on his nondominant hand and decompensated. His puzzled surgeon referred him to me for an evaluation in which it was revealed that in his culture, as the eldest son, he would have to play a musical instrument to guide his father into the next world upon the man’s death. Without the tip of his finger, he could not play the instrument and would bring shame to himself and his family.
Pain, and medication to relieve it, is the primary reason most people seek healthcare after an injury. However, the expression of that pain varies widely among cultural groups. Unlike clinicians in other countries who are responsible only for understanding their own society, increasingly, American healthcare providers must deal with a wide range of ethnic and cultural differences. Psychosomatic differences are complex and often just set aside
What is the point of knowing these differences? In America, we often measure a patient’s pain by their use of medication. We measure their compliance by whether they manage medication as expected and take it exactly as prescribed.
But many non-Americans believe Western medication is simply too strong, and compliance only occurs until symptoms improve, or if no side effects develop. The concept of taking an antidepressant for a week while awaiting adequate blood levels, and dealing with initial side effects, is out of the question for some.
Even the reason for overuse of narcotics can be variable. Some cultures are expected to express their pain openly and expect immediate relief, preferably through injectable or IV medications.
Conversely, other cultures may be reluctant to express pain, believing it is God’s will or a punishment for past sins.
In still other populations, it is generally acceptable to be in the sick role, regardless of the reason, without feeling guilty. Family steps in and assumes the responsibility of daily life, and visions and hallucinations are not seen as signs of mental illness.
So what do you do with the patient who appears noncompliant with their medication or the treatment plan?
You must know:
Their cultural expectations regarding pain and its relief
Their family support system and acceptance of disability
Their understanding of the treatment plan
Their plans for the future
Their ability to look objectively at chronic limitations and willingness to work on an alternate future course
This information is clearly critical to effective patient management, and can only come from a psychological evaluation that addresses somatic symptom (psychosomatic) disorders.