Somatization in refugees: a review

Somatization in refugees: a review Hans G. Rohlof, Jeroen W. Knipscheer & Rolf J. Kleber Social Psychiatry and Psychiatric Epidemiology The International Journal for Research in Social and Genetic Epidemiology and Mental Health Services ISSN 0933-7954 Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0877-1 1 23 Your article is protected by copyright and all rights are held exclusively by SpringerVerlag Berlin Heidelberg. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0877-1 ORIGINAL PAPER Somatization in refugees: a review Hans G. Rohlof • Jeroen W. Knipscheer Rolf J. Kleber • Received: 25 March 2013 / Accepted: 14 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014 Abstract Purpose To present a review of the literature concerning medically unexplained physical symptoms in refugees. Methods We outline a variety of definitions and explanations of somatization, as well as the role of culture in the concept of disease. In addition, we present a review of the epidemiological literature about somatization in refugees. Results Refugees from non-Western countries exhibit more unexplained somatic symptoms than the general Western population. Although different studies have employed different methodologies and are therefore difficult to compare, it can be concluded that refugees form a particular population in which somatization is prominent. Conclusions Potential, not mutually exclusive, explanations of the high number of somatic symptoms in the refugee population include general psychopathology, specifically traumatisation, results of torture, and stigmatisation of psychiatric care. There are implications for assessment, clinical treatment and further research concerning somatization in refugees. Keywords Refugees
Migrants
Somatization
Medically unexplained physical symptoms
Traumatization H. G. Rohlof (&) Foundation Centrum’45/Foundation Arq, Rijnzichtweg 35, 2342 AX Oegstgeest, The Netherlands e-mail: [email protected] J. W. Knipscheer
R. J. Kleber Utrecht University/Foundation Arq, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands Introduction Somatization poses a difficult problem in psychiatric practice. Both psychiatrists and patients can become frustrated, because they may both be under the impression that the other cannot understand their point of view: psychiatrists because they may see somatization as a reason why the patients reject their diagnoses and subsequent interventions; psychiatric patients because they have the feeling that their demands for further physical examination and physical therapies are not being met. In fact, the problem starts with general practitioners, who do not provide sufficient explanations for medically unexplained physical symptoms, and tend to suggest a physical disease [1, 2]. This problem is especially present when there is contact between clinicians educated in the West and non-Western migrant patients [3–6]. In our center for traumatized refugees,1 we encounter many patients, who exhibit medically unexplained physical symptoms, probably more so than in the realm of psychiatric practice for non-migrants. Many of these patients expect to be predominantly treated for their somatic symptoms rather than for their mental problems. Often, this expectation results in misunderstandings and problems in the therapeutic process. In this article, we present a review of the literature regarding medically unexplained physical symptoms in refugees. Our first question is: do non-Western refugees have a greater tendency to somatize than other ethnic groups (in the general population, in primary care as well as in clinical psychiatry)? Because many refugees have been traumatized [7], our second question is: is there a 1 A branch of Foundation Centrum ’45, the National Expert Centre for the Treatment of Victims of Persecution, War and Violence, Rijnzichtweg 35, 2342 AX Oegstgeest. 123 Author's personal copy Soc Psychiatry Psychiatr Epidemiol connection between somatization and traumatization? In the discussion, we describe diverse theoretical models which offer explanations for higher rates of somatization in refugees. Theoretical considerations Somatization, or the expression of one or more physical symptoms which cannot be explained by medical examination, is a rather complex phenomenon. In the scientific literature, different definitions of somatization are used: varying from a clinical diagnosis or more specifically the somatization disorder according to Diagnostic and Statistical Manual (DSM) [8], to a high score on a somatization scale or subscale like the Hopkins Symptom Checklist. We will use the definition provided by Lipowski [9], who stated that somatization is ‘a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them’ (page 1359). This definition includes not only the psychological aspects of somatic complaints, but also aspects connected to the medical system. One could consider, for instance, the reinforcing effect of repeated medical investigation on somatization (e.g. ‘If they have spent so much time examining me, I must have a serious disease’), or the effects of attention and care. In addition, secondary gain (e.g. receiving illness benefits in the form of financial compensation) could influence somatization. The definition of Lipowski ignores the influences of cultural beliefs of the patient. For instance, stigma surrounding seeking psychiatric treatment can also enhance somatization; this is dependent on the culture of the individual [10, 11]. There are at least three different ways to approach somatization. According to Kirmayer and Robbins [12], somatization can be considered as: (a) a syndrome of medically unexplained somatic symptoms; (b) hypochondriasis, or (c) somatic signs and symptoms of psychiatric disorders. The first concept also refers to medical conditions that are as of yet unknown. When a patient experiences pain, functional symptoms or functional deficits, he or she can assume that s/he has a somatic disease. Newer techniques, such as computerized tomography (CT scanning) and magnetic resonance imaging (MRI) have assisted physicians in diagnostic facilities, but still are not perfect in detecting all pathology. When a physician cannot find any indication of organic pathology, then somatization or, depending on the symptoms, a somatoform disorder may be diagnosed. In fact, the diagnosis of somatization, in this case, is an ‘exclusion’ diagnosis, i.e. a diagnosis made by 123 the exclusion of other diseases. In terms of the classification system of the DSM-IV [8], this syndrome of somatization would be classified as an undifferentiated somatoform disorder (DSM-IV code: 300.81). The definition of an undifferentiated somatoform disorder in this system is: one or more physical complaints that cannot be fully explained by any known general medical condition or the direct effects of a substance and persist for 6 months or longer. In more severe cases, this would become classified as a somatization disorder (DSM-IV code: 300.82). The symptoms may derive from a permanent state of arousal in which the autonomous nervous system is activated, and in which, for instance, muscle contractions cause headaches and aches in the back and limbs. In refugees, this form of somatization can occur as a result of hyperarousal, a manifestation of anxiousness without the full diagnosis of an anxiety disorder. The second concept, hypochondriasis (DSM-IV code: 300.7), is a serious psychiatric disorder, in which patients are convinced that they have a serious disease, with all the signs of this disease. This belief is firmly grounded on a false interpretation of somatic signs. Patients with this syndrome have an almost delusional belief in their disease or are obsessed by their symptoms, and it is difficult to convince them of other interpretations of the signs. Refugees, mostly from non-Western societies, sometimes suffer from this condition as a culturally specific sign of distress: general distress is translated into a conviction that they have a specific disease. There is a difference between somatization disorder and hypochondriasis, when compared with the difference between anxiety and psychosis: fears become convictions. The third approach to somatization is to regard it as being a part of the symptoms of mental disorders. Mental disorders are also, by definition, expressed in a somatic way. For instance, physical symptoms, such as constipation, amenorrhea or a dry mouth can be present in cases of depression. In anxiety disorders, somatic expressions, such as diarrhea or hyperhidrosis can occur. In patients with a post traumatic stress disorder (PTSD), symptoms, such as quick respiration, palpitations and hyperhidrosis are often seen when the disorder is triggered by an impulse which resembles the original traumatic experience. There is also a connection between pain and PTSD symptoms. In a large study of traumatic injury patients, mostly from motor vehicle accidents, Liedl et al. [13] found a strong relationship between pain and PTSD. Arousal symptoms accounted for pain becoming chronic, and on the other hand pain symptoms resulted in arousal and re-experiencing symptoms becoming chronic. In the classification system of the DSM-IV (APA 2000), many of these somatic symptoms, but not all are included in the classification of a specific psychiatric disorder. Refugees often exhibit Author's personal copy Soc Psychiatry Psychiatr Epidemiol Most people somatize once in a while without going to a physician. When we use the former formulated definition of somatization according to Lipowski [9], we see that a large number of people show somatization by presenting complaints to their general practitioner once, and not coming again after being reassured that they do not have any serious disease. According to a review [16] (total N = 16.116, all performed in the United States), three studies reported found a percentage of presented somatic symptoms in primary care of around 33 %, while the other two studies found percentages of 74 and 20 %, but a different method of classification was used. In an older study in the Netherlands, it was estimated that 20 % of somatic symptoms could not be medically explained [17]. Therefore, stating that one-third of patients in primary care and in the general population has medically unexplained physical symptoms appears to be a reasonable estimate. differences in symptom presentation between a Chinese group of psychiatric outpatients and a Euro-Canadian group. They concluded that Chinese patients reported more somatic symptoms on spontaneous problem report and in a structured clinical interview than Euro-Canadian patients. Because somatic presentations are existent worldwide, they regard psychologization (i.e. the translation of feelings of unwell being into psychological expressions) as more culturally specific than somatization, because larger population groups in the world use somatic than psychological symptom presentations. Psychologization would be more characteristic for the western population. However, in a large study conducted by the World Health Organization (WHO) about somatization in primary care, Gureje et al. [21] found no substantial differences in the prevalence rates of the somatization disorder according to the criteria of DSM-IV in 14 different catchment areas around the world: the overall prevalence was approximately 0.9 %. To explain this low percentage, it is important to consider that there are quite strict rules for this diagnosis in DSM-IV; namely, eight different symptoms in different somatic fields, a duration of several years and beginning before 30 years of age. Only in Rio de Janeiro and in Santiago de Chile significantly more somatization disorders were present. Besides somatization disorder, Gureje and colleagues [22] also examined a less restrictively defined form of somatization, as assessed by the Somatic Symptom Index (SSI0). The SSI was said to have a positive outcome when four or more unexplained somatic symptoms for men and six or more unexplained somatic symptoms for women were determined. The overall frequency estimated using the SSI was 19.7 %, and the estimates in 10 of the 15 catchment areas were close to or even higher than this value. Again, the rates in the two South American areas were much higher than the overall rate. However, this study was heavily criticized, since it was conducted in large cities and not in more rural regions where people are less Westernized. Interesting enough, Kebede and Alem [23] found that the prevalence rate of somatization disorder among the general population in Addis Abeba, Ethiopia was 3.1 %. Somatization in non western societies Somatization and traumatization At this point, it would be interesting to know the frequency of somatization in developing countries and in ethnic minorities. In a study performed on patients in primary care in India, about 65 % of all patients showed somatization of psychological problems and unexplained somatic complaints, as defined by the authors [18]. In a study in the United Kingdom, significantly higher levels of somatization were reported among Asian people than among native English people [19]. Ryder et al. [20] performed a study on Because a major part of the refugees have experienced traumatic events, traumatization can be an important factor in the origin of somatization. According to a review study of 33 studies in this field, patients with medically unexplained physical symptoms generally report more traumatic events. The relation with symptom severity and trauma was reported in few studies, for irritable bowel syndrome, conversion disorder and somatization disorder. Neuroendocrinological studies showed that long-lasting effects on somatic symptoms. Psychiatric disorders are more common among refugees, but they initially express these disorders as somatic symptoms [14]. Kirmayer and Young [15] offered an integrative model of somatization. They mentioned different physiological, psychological, interpersonal, and sociocultural factors that could contribute to vicious cycles of symptom amplification. They described these cycles as: (a) illness worry and catastrophical thoughts resulting in increased emotional arousal and anxiety causing somatic symptoms due to autonomic arousal; (b) avoidance of activity and sick role behavior leading to physical deconditioning and sleep disturbance; (c) cultural interpretations of sick role behavior leading to reattributions for sensations and distress; and (d) sick role behavior leading to interpersonal conflicts and emotional arousal. In this model, they also mentioned help-seeking behavior and its positive consequences and disability insurance which may worsen the symptoms. Of course medically unexplained symptoms can affect individuals in their daily life, since they influence the daily functions of the individual. Prevalence of somatization 123 Author's personal copy Soc Psychiatry Psychiatr Epidemiol Table 1 Fluxogram of the search of the studies Total amount of studies after deduplicating 685 Rest Studies about diagnostics and assessment 170 515 Studies about treatment of somatization Anthropological and social psychological studies on somatization Case reports Neurobiology, education Epidemiology, non-refugees (migrants, internally displaced persons) Epidemiology, but not about somatization Studies in foreign languages 78 445 112 333 13 320 4 316 132 184 121 63 39 24 the stress sensitivity of the Hypophyse-Pituitary-Adrenal (HPA) axis are the result of early traumata and can be associated with increased chances of medically unexplained physical symptoms. Other review studies confirm these findings [24–26]. Method Study inclusion and exclusion criteria To be included in the systematic review, the studies had to meet the following criteria. The population had to be refugees with somatization complaints. Studies on migrants were excluded, since we were interested in forced migrants only. The studies should contain data on epidemiology. Studies that were only about treatment, diagnostics, neurobiology or anthropology and health policy were excluded. A few case reports were also excluded. Non-English language studies were excluded, because of the problem of controlling the full study. And at last, some different studies about other subjects such as religion and discrimination were excluded. For a full report of the inclusion and exclusion criteria, see the fluxogram (Table 1). Search strategy Ovid MedlineÒ and PsycInfo were searched from 1985 up to 1.7.2013. The keywords were refugees AND {somatization OR somatisation OR medically unexplained physical symptoms} {no related terms}. Abstracts of all studies identified by the search strategy were reviewed and included or excluded, based on the above-stated inclusion and exclusion criteria. Search outcome The broad search gave 773 references. After removing the duplicates, this number was reduced to 684. The exclusion 123 of articles as shown in the fluxogram lead to 23 epidemiological studies, 11 general population studies, 8 primary health care studies, and 5 clinical psychiatry studies. The instruments used in the studies were diverse. Therefore, it is hard to compare the studies. The instruments used will be discussed in the description of each study. The instruments do show a certain degree of somatization, but none of the instruments give a clear cutoff point for the somatization disorder. Prevalence of somatization among refugees in the general population First, we will present data in refugees in the general population. Epidemiological studies on somatization have been performed using the general population and those in primary care. These findings provide a better insight than research using patients in the psychiatric services because of the selection of patients. Our literature search concerning the frequencies of somatic symptoms in refugees revealed eleven community studies on refugees in Western countries; for the results, see Table 1. A 3-year follow-up study of 240 refugees in a community in Norway was performed by Lie [27]. The focus of the study was to look at the development of psychological symptoms, but she also looked at general health. The author used a scale from 1 to 10 to measure the selfreported health situation of the refugees. Next to this she asked the refugees for a list of bodily symptoms. The importance of the study lies in the finding that psychopathology tends to increase in refugees after resettlement. Somatization in a non-patient population of 97 Hmong refugees was studied by Westermeyer et al. [28]. Four different measures of somatization were employed, including a 12-item self-rating scale, which is part of the Symptom Checklist-90, a single-item global rating of the Brief Psychiatric Rating Scale, and somatic subscales of the two Hamilton interview rating scales, the Hamilton Depression Scale and the Hamilton Anxiety Scale. Next to this, demographic variables were collected, medical problems were scored, medical treatment seeking, psychiatric problems and symptoms, and a rating for psychosocial adaptation and acculturation were described. Regression analysis revealed some interesting correlations. Somatization was associated with depressive symptoms. More education was associated with less somatization. And, interesting enough, those subjects who were fluent in English with considerable psychopathology, were more apt to somatize than those with comparable psychopathology but less skill in English. The authors concluded that somatization is associated with a failure to adapt to the psychological language of the western society. Author's personal copy Soc Psychiatry Psychiatr Epidemiol Beiser et al. [29] performed a study among 1,348 Southeast Asian refugees, whom they compared to 319 native residents of Vancouver using different measures. They studied somatization by a 16-item scale composed by several questions from the Self Report Questionnaire, items from DSM-III, and the Senegal Health Scale. They consider this scale as a culturally sensitive scale to be used for refugees. Their conclusion was that after resettling in British Columbia, south-east Asian refugees did not show more psychopathology or somatization than local residents. Probably this finding has to do with the good reception of Southeast Asian refugees in Canada. Gerritsen et al. [30] explored the physical and mental health of Afghan, Iranian, and Somali asylum seekers (N = 232) (refugees without a permit to stay) and refugees (N = 178) (with a permit to stay) living in the Netherlands. They used the Medical Outcome Study (MOS) 36-item list to measure physical health. Approximately half of all respondents suffered from more than one chronic condition. The mean number of chronic conditions was 2.0 for the entire study population. The physical health and quality of life of Iraqi asylum seekers in the Netherlands was studied by Laban et al. [14]. They compared two groups of asylum seekers: one group who had lived shorter than 2 years in the Netherlands (N = 143) versus one group who had lived there for more than 2 years (N = 151). They used among other scales a newly constructed 22-item scale, dealing with perceived physical health and chronic physical health problems and physical handicaps. The length of stay in the asylum procedure was the strongest predictor for a low overall quality of life and for physical health. No comparison was made with the general population on these scales. Thus, this research showed that the long asylum procedure causing much uncertainty created thus more physical complaints. Geltman et al. [31] looked at functional health outcomes of 304 unaccompanied refugee minors from Sudan in the United States using the Harvard Trauma Questionnaire (HTQ) and the Child Health Questionnaire (CHQ) together with questions about use of health services. Mental health counseling was also high (45 %), but there was no difference between those with and without PTSD. Their conclusion was that refugee minors had a great degree of somatization, resulting in an overuse of general health services. Fenta et al. [32] studied somatic symptoms in a sample of 342 adult Ethiopian refugees in Canada, using the somatization disorder module of the Diagnostic Interview Schedule. Somatic symptom level was significantly associated with major depression and PTSD. In addition, somatic symptom level was associated with older age, premigration trauma, post-migration stressful life events and limited English fluency. The authors suggested a cultural tendency toward presenting somatic symptoms for mental health issues. In Finland, a study was performed about the mental and somatic health status of 78 torture survivors, refugees from the Middle East, Central Africa, Southern Asia and Southeastern Europe [33]. For the somatic health status, the investigators did not use a questionnaire, but asked for the number of complaints. In comparing these four groups, they found out that the European group had the highest number of somatic complaints than the other population groups, with the Central African group having the lowest number. There was a connection with PTSD and depression: in the Southeastern European group the levels of PTSD and depression symptoms were higher. In Australia, Schweitzer et al. [34] looked at the mental health of 70 Burmese refugees. They studied somatization, too, from the subscale of the Hopkins Symptom Checklist (HSCL)-37. Somatization was mostly due to post-migration living difficulties and not so much to pre-migration traumatic events. In a study among 74 predominant male Somali refugees, Bentley et al. [35] looked at the relation between somatic complaints and mental symptoms. They used the subscale for somatization from the Symptom Checklist-90. They found a mean of somatization in this group of 18.9 %. There was an indirect effect of somatic complaints on anxiety and depression but not on PTSD in this group. Medical information for participants was not available to rule out medically explainable physical symptoms. Hollifield et al. [36] looked at a group of 252 refugees, 135 of them being Vietnamese and 117 Kurdish, using an own developed scale, the New Mexico Refugee Symptom Checklist (NMRSCL)-121, containing somatic subscales. The refugees stayed for a mean of 7 years in the United States. Although the severity scores were the highest for depression and PTSD symptoms, all participants scored also high on the different somatic subscales. Prevalence of somatization among refugees in primary health care Next, we looked at research findings of the seven studies on somatic symptoms in refugees in primary care (see Table 2). Lin et al. [37] conducted an investigation using 261 Asian refugees and 265 Chinese and Filipino migrants in primary care in the United States, and compared the two groups. Somatization accounted for 35 % of visits to doctors, according to a clinical diagnosis. The percentage of somatization in the immigrant group was 27 %, in the refugee group it was 42 %. The most common complaints 123 Author's personal copy Soc Psychiatry Psychiatr Epidemiol Table 2 Research on somatic complaints in refugees in the general population Author Method Percentage with somatic complaints Types of complaints Lie [27] Self perceptions of general health, perceptions of life and health situation on a 1–10 scale, list of 7 somatic complaints 50 % poor or bad health. Perception of general life and health situation 4.8/10 Heart symptoms (56 %) 4 different somatization scales 44 % borderline or abnormal scores List of 16 somatic items 5.0 % of refugees showed somatization vs. 4.8 % of the general population (non significant) MOS-SF 36 42 % of refugees, 59 % of asylum seekers poor health Community study in Norway* Westermeyer et al. [28] Bodily pains (40 %) Community study in USA Beiser et al. [29] Community study in Canada Gerritsen et al. [30] Community study in The Netherlands Laban et al. [14] Asylum seekers in reception camps in The Netherlands Geltman et al. [31] Back (32 %) Migraine/ headache (32 %) Self-developed questionnaire, WhoQoL A longer period of asylum causes poorer physical health CHQ in children 76 % Minors in the community in th USA Fenta et al. [32] DIS Headaches, stomach aches, sleep disturbances 63.2 % one symptom 12.9 % five or more Community study in Canada Schubert and Punamäki [33] Neck/shoulder (33 %) Structured interviews 16.5 % Southeastern Europe, 10.89 % African HSCL-subscale 37 % SCL-subscale 18.9 % NMRSCL 1.9 on scale 0–4 Torture survivors in Finland Schweitzer et al. [34] Burmese in Australia Bentley et al. [35] Somali in the USA *On a scale of 10, showing a significant difference between refugees who sought psychiatric treatment and refugees who did not Hollifield et al. [36] Community in USA were headaches, abdominal pains, and lower back pains. The authors concluded that somatization is an important health problem among both immigrants and refugees, but that it is a greater problem for refugees. A study of 70 Tibetan refugees in India, 35 who had been tortured, and 35 who had not been tortured (80 % of 123 On average 48 somatic symptoms this sample were nuns), was conducted [38]. Although tortured refugees scored higher on anxiety, there were no differences in terms of scores for depression and somatic symptoms. The subjects had a mean score of 1.75 out of 5 in the somatic subscales of the Hopkins Symptom Checklist, which is higher than the cut-off point for somatization. Author's personal copy Soc Psychiatry Psychiatr Epidemiol Table 3 Research on somatic complaints in refugees in primary care Mean number of complaints Types of complaints Author Method Percentage with somatic complaints Lin et al. [37] Medical files, ICD-9, reason for visit classifications 42 % of refugees Headache (7.5 %) 27 % of migrants Stomach ache (6.6 %) Holtz [38] HSCL-25, 8 somatic items Lower back pain (5.8 %) Stomach ache (19 %) 1.75 Headache (16 %) Muscle, bone and joint problems (49 %) Crescenzi et al. [39] HSCL-25, list of 8 somatic complaints Van Ommeren [40] Checklist of 25 somatic complaints 3.45 84 % in tortured refugees Headache, bellyache, pains over the whole body, panic attacks, unexplained signs of paralysis, heart complaints, insomnia 2.5 of tortured subjects 1.8 of non tortured subjects Thijs and Van Willigen [41] Questionnaires of somatic complaints and anamnesis 85 % questionnaire Weakness/loss of weight (50 %) 66 % anamnesis Complaints of movement system (25 %) Hondius et al. [42] Prospective study with one interview 75 % Junod Perron et al. [44] Structured interviews Different outcomes Gynecological complaints (35 %) Headache 2.5 Stomach ache (19 %) Headache (16 %) Muscle, bone and joint pains (49 %) Refugees from Tibet (N = 150) were also investigated in another study: 74 of the subjects of this study had never been imprisoned and 76 had been previously imprisoned [39]. In the total study population, there was a high rate of depression and somatic symptoms according to the Hopkins Symptoms Checklist. The two groups had the same number of somatic complaints. However, the formerly imprisoned group had significantly higher anxiety scores. Van Ommeren et al. [40] looked at refugees from Bhutan in Nepal, 526 who had been tortured and 526 who had not. They used a new checklist of 25 somatic complaints, covering nervous, musculoskeletal, gastrointestinal, genitourinary, cardiovascular, and respiratory system symptoms, and weakness. They found a significantly higher amount of non-specific somatic complaints in the tortured group: 2.5 versus 1.8. 84 % of the tortured group had somatic complaints. Similarly, the tortured group, as compared to the non-tortured group, had a higher number of organ systems with somatic complaints, 2.2 versus 1.5. In their study, a strong connection between physical complaints and psychopathology was reported (Table 3). Refugees living in the Netherlands presenting for primary care were studied [41]). Of them 85 % had somatic complaints, but for 66 % of them, a medical diagnosis Headache (75 %), fatigue (45 %), bone and joint pains (65 %) could not be made. The most common complaints were general weakness, gynecological complaints, headaches, and complaints about their movements. A prospective study among 156 refugees from Turkey and Iran living in the Netherlands was conducted by Hondius et al. [42]. The International Classification of Primary Care was used to score medical disorders. 75 % of the patients had somatic complaints, but 70 % did not have a somatic diagnosis. Furthermore, the refugees attributed their somatic and psychological complaints to torture, imprisonment and persecution. A current somatic illness was mentioned as a cause for the somatic complaints. Psychological complaints were attributed to worries relating to the post migration situation. Retrospectively was looked at 480 refugees from the Middle East and Latin America. Of these refugees, 84 % showed somatic complaints, and in 73 % of the cases a somatic diagnosis could not be made, thus showing a large tendency to somatization. Oldsen [43] looked at the occurrence of DSM-IV diagnoses of PTSD and somatization disorder among Iraqi refugees in the United States, in services in resettlement organizations. Depending on the specific service, prevalence rates of PTSD (50–75 %) and somatization (25–50 %) were quite high in this study, with a co- 123 Author's personal copy Soc Psychiatry Psychiatr Epidemiol Table 4 Research on somatic complaints in refugees in clinical psychiatry Author Method Outcome Raghavan et al. [45] BSI subscale 37.1 % De Williams et al. [46] Structured interviews 78 % Van Wyk et al. [47] HSCL subscale 1.62 on a scale 0–4 Hinton et al. [48] CSSI 2.4 on a scale 0–4 in severe PTSD Bettancourt et al. [49] Clinical assessment in children 26.8 % occurrence of 50–75 % of the cases. Most refugees with somatization did not meet the full criteria of DSM-IV for somatization disorder. She advised an addition of somatization and life functioning problems to the five criteria for PTSD in the case of refugees. In a small group of 26 refugees from former Yugoslavia at a general medicine clinic, Junod Perron et al. [44] conducted semi-structured interviews to look at illness perspectives. They found headaches (20/26), fatigue (12/26), and bone and joint pains (17/26) as the most prominent somatic symptoms. Prevalence of somatization in clinical psychiatry We found five studies on refugees and somatization in clinical psychiatry (see Table 4). Raghavan et al. [45] looked at symptom reduction in a multinational sample of 172 refugees in the Unites States, all survivors of torture. They used the Brief Symptom Inventory on Somatization, and found at the start of the study an elevation on this scale in 37.1 % of the participants. After a standard treatment program, this number was lowered to 22.1 %, much less than the improvement on PTSD and depression. Refugee survivors of torture (N = 178) were studied in a specialist center in the UK [46]. The investigators used structured interviews to measure pain complaints. Of this group, 78 % reported having persistent multiple pains, mainly in the head and low back. There was an association between rape and abdominal pain in females and anal pain in men. Van Wyk et al. [47] looked at symptom reduction in a study about the effect of mental health interventions in Burmese refugees. They used the HSCL-37-subscale for somatization to measure the burden of somatic complaints. At baseline, they found a mean of somatization of 1.62, on a scale of 0–4. Although there is no cutoff for somatization in this scale, this means a moderate high amount of symptoms. The relationship of PTSD to somatic complaints was studied by Hinton et al. [48]. They constructed the Cambodian Somatic Symptom and Syndrome Inventory, a 123 37-item scale built on the experience with usual complaints from Cambodian patients. They did a survey among 226 Cambodian outpatients. There was a large correlation between a high score on the somatic scale and a PTSD Checklist, the PCL. The Cambodian patients scored high on ‘thinking a lot’, which is connected to PTSD symptoms, and on ‘fear on fainting and dying upon standing up’, which is a symptom connected to so-called khyâl attacks, khyâl being a wind-like substance thought to flow throughout the body. War-affected refugee children (n = 60) were studied in a center in Boston, USA [49]. Clinical assessments were used to identify different mental and somatic symptoms. Somatization was identified in 26.8 % of the children when compared with 30.4 % PTSD, 26.8 % general anxiety, 21.4 % traumatic grief, and 21.4 % behavior problems. Explanations of somatization among refugees There are many possible explanations for our findings with regard to somatization among refugees. As a result, various theories for somatization in non-Western patients have been presented [15, 50, 51]. However, it is important to bear in mind that many of the explanations are also valid for Western patients. We describe six relevant explanations. Somatic disease At first, it is crucial to realize that somatization or somatic complaints may be the result of a yet unknown somatic disease. A thorough somatic examination before commencing psychiatric treatment may show, in many but not all cases, the existence of such a disease. Somatic examination should be extensive and not be based on superficial stereotypes (e.g. ‘Another psychiatric patient who thinks he has cancer’). We should also keep in mind that some diseases have a latency period and become visible and detectable at a later phase. In some cases, it is wise to opt for a re-examination. Refugees, especially those from a non-Western background, are in danger of being misdiagnosed, since communication with them may be difficult, because of poor language abilities and poor knowledge of the medical system. Psychological conflict The second theory is that somatic complaints without a somatic disease are an expression of a psychological conflict. This is the main theory that psychiatrists and psychotherapists use; however, importantly, their patients do not. This could easily result in misunderstandings and even conflict in the treatment process. This theory is reminiscent Author's personal copy Soc Psychiatry Psychiatr Epidemiol of certain old psychodynamically grounded psychosomatic theories, especially the so-called specificity theory where certain somatic diseases, such as asthma and stomach ulcers were believed to result from certain unsolved conflicts [52]. This theoretical framework has been abandoned, and has since long been replaced by the general stress theory [53]. Culture specific The third explanation is that somatization is a culturally specific sign of distress. In some cultures, psychiatric diseases as defined by the Western nomenclature are unknown. Psychiatric diseases are here explained on a spiritual, supernatural, or somatic level. Caribbean voodoo and Chinese neurasthenia are examples of this, as is French crise-de-foie, in which general exhaustion is thought to be caused by liver problems. Somatization can be seen as a way in which to express distress which is socially and culturally acceptable [15, 20]. In refugees this is shown by several studies in Cambodian and other patients by Hinton et al. [54, 55]. In-depth analyses of their psychological and somatic complaints showed an illness concept, in which traditional believes play a major role. In Cambodian patients the belief in khyâl, a wind-like phenomenon in the body, can lead to sensations of dizziness and panic. The authors consider sensations as key sites of embodying metaphors, from bodily experiences, of memory making, from certain traumatic experiences, and of self-fashioning, as in pain connected to tortures. Hinton et al. emphasize the importance of an examination of somatic symptoms and the associated cultural meanings in especially refugees. Somatic sensations are in their view generated by a combination of trauma associations, catastrophic cognitions, and metaphor-guided somatization. They call this the ‘multiplex model’ of somatic symptoms since it integrates sensory, cognitive, linguistic, memory, and interpersonal processes. They illustrate their case with numerous examples. We refer the reader to this literature [54–56]. Alexithymia Another explanation is alexithymia, which is the inability to express emotions. Emotions therefore seek a somatic form of expression. People with alexithymia have a greater sensibility in terms of somatic signals than emotional signals. In a large review of the relevant literature, an association between somatization and alexithymia has been established [57]. However, there are still questions, because most of the studies that were reviewed used questionnaires to establish somatization, and not a physical examination. Furthermore, it appears that alexithymia is more often encountered in non-Western cultures [58]. Stigma The fifth explanation deals with the fear of stigmatization that patients may encounter when they express psychological problems. They consciously or unconsciously prefer to present somatic problems rather than psychological problems because of the fear of being called insane by their doctor, their family, or others. The health system is also oriented towards somatic problems. In many countries, having a somatic disease makes it easier to profit from illness benefits. Somatic diseases legitimize illness. The general opinion is that a doctor will listen more carefully when the complaint concerns somatic symptoms. In countries, where people see psychiatry as a care system specifically for schizophrenics, patients have a greater fear of being stigmatized if they were to seek psychiatric treatment for depression or an anxiety disorder. In many non-Western countries, this is certainly the case [10]. Trauma Patients who have been tortured often show chronic symptoms of pain and dysfunction in the parts of their body where they were tortured, without any objective signs of lesion. Owing to the fact that their somatic symptoms are linked with feelings of hate, anger, and sadness, these symptoms tend to become chronic [13, 40]. The same phenomenon is encountered in veterans who have been wounded or otherwise hurt. The Gulf War syndrome is said to be an example of this mix of somatic and psychological factors. Sometimes this is difficult to distinguish: chronic somatic diseases can of course also be responsible for psychological distress. It has been stated that deep-rooted emotions prevent somatic symptoms from being cured, when only a somatic therapy is used. Psychotherapy should be added to the treatment [59]. Conclusions and discussion The questions central to this paper concerned the postulated tendency of non-Western refugees to exhibit somatization, and the existence of a connection between somatization and traumatization. Four general conclusions can be drawn: 1. 2. The prevalence of the somatization disorder has shown to be equal in populations all over the world, with exceptions for populations in Latin America and maybe in parts of Africa. The number of medically unexplained physical symptoms (MUS) among refugees is generally higher than among non-refugees. Unfortunately, the studies are not 123 Author's personal copy Soc Psychiatry Psychiatr Epidemiol 3. 4. comparable. Different definitions for somatization were used, such as clinical assessments and conclusions from questionnaires. Different somatization questionnaires were used, with different cutoff points for somatization. In addition, most studies did not look at coexisting somatic disorders; a thorough somatic examination is rarely included. Thus, we can only speak of a trend that high levels of MUS occur in refugees. In most cases, a full diagnosis of the somatization disorder could not be reached. Somatization in refugees is strongly connected with psychopathology and possibly also with traumatization, and with negative life events. A large review of the literature concerning the prevalence of psychopathology in refugees showed that refugees are 10 times more likely to have PTSD than age-matched individuals from the general population [7]. The prevalence of depression and generalized anxiety disorder appears to be the same in refugees as in the general population. Whether somatization derives from torture is not clear [38–40]. The different studies on somatization and torture have different outcomes. It is possible that this is a result of the broad definition of torture in this literature, including not only physical methods, but also psychological torture. In future research it would be good to look for a direct connection between physical torture and somatization. Somatization in refugees might be perceived as a specific idiom of distress [12], which accompanies PTSD. This explains the larger prevalence of somatization in refugees compared to other migrants [37]. In addition, it seems that stigmatization prevents refugees from receiving psychiatric care. Refugees prefer to be referred to medical services, rather than to psychiatric institutions, as they fear that they will be considered mad by their compatriots [14]. This fear of stigmatization influences both the symptom expression of the patients and the referral strategy of the general practitioner. Stigmatization plays a role in all patients with somatization, but non-Western refugees seem more vulnerable for this as a result of their cultural opinions. Future research More research will need to be conducted to compare somatization between groups of refugees and other population groups, and in the community as well as in the health care system. In this research, it would be advisable to use the same instruments, with the same cutoff points for somatization for the comparison groups. When translated, there should be a back-and-forward translation, and after 123 that a validation of the questionnaire. Of course, the groups should be matched in terms of demographic variables. A somatic examination of individuals from both groups should be performed, with additional elementary laboratory examinations. It is clear that a comparison of the results of questionnaires is not enough. 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