LETTERS TO THE EDITOR Reconsidering Somatic Presentation of Generalized Anxiety Disorder in Nepal To the Editor: R esearching somatic presentation as an aspect of psychiatric disorders is crucial to the development of mental health services in a globalizing world. The work of Hoge et al. (2006) is an important contribution to identifying cultural differences in psychiatric pre- sentation. Hoge et al.’s comparison of generalized anxiety disorder in the United States and Nepal suggests that somatic complaints are more common among Kathmandu patients, while psy- chological complaints characterize Bos- ton patients. However, on the basis of our research and clinical experiences in Nepal, we would like to raise some con- cerns regarding the interpretation of these results. First, the symptom presentation of psychiatric populations should be ad- dressed within the context of local healthy populations. For example, the somatic items “indigestion and discom- fort in the abdomen” and “sweating” were as common in healthy controls as among generalized anxiety disorder pa- tients in the Nepali validation study of the Beck Anxiety Inventory. Further- more, more than one-third of the general population in different regions of Nepal complain of paresthesia (numbness and tingling sensations) (Kohrt and Schre- iber, 1999; Kohrt et al., 2005). This suggests that some somatic complaints may be common on a population level rather than represent a specific cultural difference in psychiatric presentation. A control group of nonpsychiatric patients would be useful to address whether rates of somatic symptoms are part of a psy- chiatric disorder or represent popula- tionwide phenomena. Second, the local burden of phys- iological disease may influence the so- matic presentation of mental illness through comorbid or underlying physio- logical disorders. In a study of somati- zation in rural Nepal, two-thirds of cases of paresthesia among individuals with depression and/or anxiety could be at- tributed to physiological comorbidity in- cluding vitamin B 12 deficiency, arthri- tis, diabetes, and neurological trauma (Kohrt et al., 2005). In the Teaching Hospital, where Hoge et al.’s Nepali sam- ple was collected, screening for thyroid dysfunction is routine in cases of sus- pected generalized anxiety disorder. How- ever, other laboratory investigations or- dered by psychiatrists are rare because of limited hospital resources, indigent pa- tient populations, and assumptions that general physicians previously have screened for physiological conditions. Presumptions of somatization among non-Western psychiatric populations may lead to neglect of thorough physi- ological examination for underlying and comorbid conditions. Third, there is the complex ques- tion of translation of symptoms. Many terms translated literally refer to physi- cal sensations. However, these are local idioms that refer to emotional and social states as much as a bodily experience (Tol et al., 2005). “Indigestion and dis- comfort in the abdomen” has almost certainly come to stand for the widely used idiom of gyastric in Nepal, a com- plex that frequently involves the lifelong management of diet and lifestyle and which should be interpreted locally be- yond a potential symptom of anxiety. And finally, there is tremendous variation in concepts of mind-body in non-Western cultures. Hoge et al.’s ci- tations regarding lack of a mind-body distinction are based on East Asian pop- ulations. However, there are prominent mind-body distinctions in Nepal where a variety of ethnic groups and associated ethnopsychologies exist. For example, four elements are common across many Sankrit-influenced ethnic groups: the body, the brain-mind, the heart-mind, and the souls. The body (saarir or jiu) is the site of physical suffering. The brain- mind (dimaag) is the organ of social consciousness and the seat of accepted rational behavior; damage to the dimaag leads one to become mad/psychotic and is the most stigmatized of emotional and behavioral disturbances. The heart-mind (man) is the organ of emotion and the site of anxiety (chinta) and sadness/de- pression (dukha). Expressions of anxiety and depression are less stigmatized than psychotic behavior, in part because of this distinction between brain-mind and heart-mind. The souls (atma, saato) are the fourth element and the target of acute fear responses. To address the underlying causes for higher scores on somatic-framed items on symptom checklists, a deeper exploration of the research participants’ mind-body dis- tinctions and explanatory models would be useful (cf. Henningsen et al., 2005). We thank the editors of JNMD for publishing Hoge et al.’s study, which raises the visibility of an understudied population and draws attention to so- matic presentation in Nepal. For future research, we suggest considering inter- pretations of somatic presentation in light of symptom distributions in normal populations, possible somatic causes, translations sensitive to local idioms of distress, and local models of mind-body distinctions. Brandon A. Kohrt, MA Department of Anthropology Emory University School of Medicine Atlanta, Georgia brandonkohrt@gmail.com Wietse A. Tol, MA Healthnet TPO/TPO Nepal Vrije University Amsterdam Amsterdam, the Netherlands Ian Harper, PhD, MA, MBBS University of Edinburgh Edinburgh, Scotland REFERENCES Henningsen P, Jakobsen T, Schiltenwolf M, Weiss M (2005) Somatization revisited: Diagnosis and perceived causes of common mental disorders. J Nerv Ment Dis. 193:85–92. Hoge EA, Tamraker SM, Christian KM, Mahara N, Mahendra KN, Pollack MH, Simon NA (2006) Cross-cultural differences in somatic presentation in patients with generalized anxiety disorder. J Nerv Ment Dis. 194:962–966. Kohrt BK, Schreiber SS (1999) Jhum-jhum: Neu- ropsychiatric symptoms in a Nepali village. Lancet. 353:1070. Kohrt BK, Kunz RD, Baldwin JL, Koirala NR, Sharma VD, Nepal MK (2005) “Somatization” and “Comorbidity”: A study of jhum-jhum and depression in rural Nepal. Ethos. 33:125–147. Tol WA, Jordans MJD, Regmi S, Sharma B (2005) Cultural challenges to psychosocial counseling in Nepal. Transcultural Psychiatry. 42:317– 333. The Journal of Nervous and Mental Disease • Volume 195, Number 6, June 2007 544