Abstract-Six hundred medical clinic attenders at the Mayo Hospital, Lahore, Pakistan, were screened using the Bradford Somatic Inventory (BSI) in Urdu.
Journal of Psychosomorir Resenrch. Vol. 35, No. Z/3, pp. 245-255. 1991. Printed in Great Britam
6
0022-3999/91 $3.00 + 03 1991 Pergamon Press plc
AN INVESTIGATION OF ‘FUNCTIONAL’ SOMATIC SYMPTOMS AMONG PATIENTS ATTENDING HOSPITAL MEDICAL CLINICS IN PAKISTAN-I. CHARACTERISTICS OF ‘NON-ORGANIC’ PATIENTS D. B. MUMFORD, I. A. K. TAREEN, M. A. Z. BAJWA, M. R. BHATTI, T. PERVAIZ and M. AYUB (Received 19 December 1989; accepted in revised,form 4 September 1990)
Abstract-Six hundred medical clinic attenders at the Mayo Hospital, Lahore, Pakistan, were screened using the Bradford Somatic Inventory (BSI) in Urdu. The physicians’ clinical diagnosis was recorded. The characteristics of mood-disordered, functional and no-diagnosis groups were compared with patients receiving organic diagnoses. Of the non-organic patients, only the mood-disordered group reported significantly more BSI symptoms than the organic group. The functional group did not have especially high scores. All groups reported a greater mean number of BSI symptoms than a student comparison group. Among the non-organic patients, there was no relationship between the number of BSI symptoms reported and sex, age, education or occupational group.
INTRODUCTION
MANY patients attending hospital medical out-patient clinics in Pakistan complain of somatic symptoms for which no physical cause is found. Often physicians assign these patients a broad diagnostic label, such as ‘gastritis’. Psychiatrists suspect that many of these patients are suffering from emotional distress, sometimes amounting to formal depressive illnesses or anxiety states. This phenomenon is not unique to Pakistan. Studies of medical clinic attenders in Britain have found that around one third of attenders have some degree of psychiatric disturbance [l, 21. There is a further number of clinic attenders whose somatic symptoms are not associated with evidence of any organic disease process, and who do not meet criteria for psychiatric disorder. ‘For want of a better term, their complaints are described as “functional”, and they occupy the hinterland between psychiatry and medicine, seeking a foothold in both specialties but finding a haven in neither’ [3]. If a reliable method of identifying patients presenting with these ‘functional’ syndromes could be devised, expensive and time-consuming investigations, and inappropriate medical treatment, might be avoided. A further psychiatric assessment could establish whether formal psychiatric treatment or counselling were required. In developing a screening instrument, the first task is to assemble the items or symptoms that may be characteristic of functional syndromes. Since the number of possible symptoms or sensations is huge, a short-cut is needed. A useful source of items is patients suffering from anxiety or depression. These patients frequently report somatic symptoms similar to those which patients present to physicians. Department of Psychiatry, Mayo Hospital and King Edward Medical College, Lahore, Pakistan. Address for correspondence and reprint requests: D. B. Mumford, Department of Psychiatry, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, U.K. 245
246
D. B.
MUMFORD
cl
d
The BraGford Sonzutic. Itwetltor!~ A new questionnaire has been developed to meet the need for a multi-ethnic somatic inventory. The Bradford Somatic Inventory (Appendix) is designed to be comprehensive with respect to patients from the Britain and the Indo-Pakistan Subcontinent. The development and initial validation of the BSI has been described elsewhere [4]; a brief summary will be given here. The initial BSI items were obtained by means of a systematic search through case-notes of English and Pakistani patients, diagnosed as suffering from anxiety, depression, hypochondriasis or hysteria. The items were constructed simultaneously in Urdu and in English. The inventory was then checked against case-notes of patients in North and South India and Nepal, and expanded so as to give 90% coverage of all somatic symptoms recorded in each of these centres. The equivalence of the Urdu and English versions was established in a bilingual college population in Lahore. The use of case-notes to derive items for a somatic inventory has a number of advantages. It enables the inventory to capture faithfully the local linguistic idiom and ensures that the item are ‘grounded in the local ethnographic context’ [5]. The present version of the BSI consists of 44 items, plus two items for males only. The questions all refer to the past one month. and not to symptoms experienced before that time. A three-choice format has been found easy to use and acceptable to patients: (1) absent; (2) present on less than I5 days during the past month; (3) present on more than 15 days during the past month. These responses are scored 0, 1 and 2 respectively. Aims The aims of this study were as follows: (I) To compare the socio-demographic characteristics of patients who present to hospital medical clinics without evidence of organic disease with those who receive physical diagnoses. (2) To investigate whether the number of somatic symptoms reported by these non-organic patients correlates with age, sex, education or occupation. (3) To determine whether the non-organic patients can be differentiated from physically-ill patients on total BSI scores or on particular symptoms. (4) To determine the efficiency with which a selected subset of BSI items might detect non-organic patients attending medical clinics. This first paper covers the first three aims. A further paper will describe the evaluation of screening tests based on these somatic symptoms, for detecting mood-disordered patients in medical clinics.
METHOD This study was conducted in the medical out-patients department of the Mayo Hospital, Lahore. The Mayo Hospital is a busy teaching hospital attached to the King Edward Medical College. one of the leading medical schools in the Indo-Pakistan Subcontinent. Treatment is free of charge and patients are predominantly from the middle and lower social classes of the city of Lahore and surrounding area. In Pakistan there is no organized system of general medical practitioners offering primary health cart and making secondary referrals for specialist hospital treatment, as in Britain. The hospital medical clinics themselves serve as a primary walk-in facility. Many of the patients have minor or trivial complaints.
Somatic
symptoms
247
in Pakistan-I.
Initial assessment in these medical clinics at the Mayo Hospital is made by a house physician or medical officer. A minority of patients are selected by junior doctors to be seen by senior medical staff. In addition to the general medical clinics, specialist neurology and cardiology clinics are held on certain weekdays: these patients are usually secondary referrals from other physicians. Recruitment of patients into this study was performed by junior medical staff from the department of psychiatry, stationed in these medical clinics. Literate patients were identified and requested to complete the Bradford Somatic Inventory in IJrdu. The doctor explained the response format to each patient, but was instructed not to offer any explanation of the questions themselves. The physical diagnosis was obtained from the senior medical person who saw the patient, and also the physician’s assessment of any psychiatric or functional component. F‘or this purpose ‘functional’ symptoms were defined as non-organic symptoms without definite evidence of a mood disorder. The physician’s confidence level in making the diagnosis and positive results from any relevant physical investigations were recorded. Additional data was collected from each patient regarding age, sex. educational level and occupation of both patient and spouse. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSSx) on an Amdahl mainframe computer at the University of Leeds.
RESULTS
Six-hundred literate patients were recruited into the study over a four-month period. The circumstances in which this study was conducted made it impossible to recruit either a consecutive sample or a truly random sample of literate attenders. Limited space in crowded clinics allowed only one or two patients to be seen at the same time, and it was not possible to cover all the medical clinics. Patients declined to take part in the study for a variety of reasons: impaired sight; anxiety about filling in lengthy forms; unfamiliarity with questionnaires; and sometimes a refusal to speak to anyone but the senior physicians. During this period, the neurology, cardiology and other medical clinics reported a total of 6656 out-patient attenders. Our sample therefore represented 9% of all clinic attenders. Of the patients in the study 394 (66%) were male and 205 (34%) were female: this sex ratio may reflect different literacy rates in Lahore. Although exact literacy rates in Lahore are unobtainable, the 1981 Pakistan Census estimated 52% literacy for males and 34% for females in urban areas, and 23% for males and 6% for females in rural areas. Mayo Hospital serves both rural and urban populations. The majority of patients come from lower and lower-middle social classes, which have the lowest literacy rates. The diagnoses made by the physicians were coded according to specialty and broad diagnostic categories. Table I shows the number of patients within each major specialty group, the percentage of males, mean age, years of education and number of BSI symptoms reported. There are separate categories for patients who were diagnosed by the physicians as functional or mood-disordered only, and for those who were given no diagnosis. Eighteen patients (3%) received both a physical and a psychiatric diagnosis: these are included in the appropriate physical diagnostic category in Table I. No normal non-clinical matched control group was available. To allow an approximate comparison, responses to the BSI in Urdu by 317 pre-clinical medical students in Lahore are also given. Characteristics
qf no-diagnosis,
One third of patients of the 203 non-organic
.functional and mood-disordered
patient groups
in this study received no physical diagnosis. The mean age patients was less than that of the 397 organic patients
24X
D. B. MUMFOKII TABLE
I.~-CHAKA~TEKISTICS
Per cent males
N Gastroenterology Neurology Respiratory Cardiology Other specialties All organic Anxiety Dcprcssion Other psychiatric Functional All mood-disordered and functmnal No diagnosis All non-organic Student group Standard
deviations
er cl/.
ok PATIENT
Mean age (yr)
31
65 66 54 79 55 65 67 40 I00 5.5
2X.X 2x.2 26.1 42.5 32.2 33.0 2X.X 29.6 20.0 25.X
(12.9) (11.X) (13.3) (14.7) (16.3) ( 15.5) (9.1) (10.5) (6.6) (9.7)
79 124 203 317
62 71 77 75
27.3 28.3 27.9 19.0
(9.4) ( 12.2) (I 1.2) (0.9)
IO0 30 65 II5 Xl 397 40
z
GKOLPS
Years ol education 9.7 10.7 9.6 9.7 Y.8 9.X II.0 9.2 13.3 I I .o
(3.0) (2.4) (2.0) (3.3) (2.9) (3.0) (3.2) (2.9) (3.5) (3.0)
10.9 (3.1) IO. I (2.5) 10.4 (2.X) 14 (approx)
Number of BSI symptoms 19.0 (10.3) 17.6 (X.1) 15.7 (X.2) 20.2 (X.9) 18.5 (9.X) IX.5 (9.4) 22.x (9.1) 21.2 (7.1) 12.0 (X.5) 18.9 (9 0) 20.x IX.4 19.3 9.6
(9. I ) (9.9) (9.6) (6.7)
given in parenthcscs
(difference = 5.07 yr. 95% CI 2.67-~7.47): this difference became non-significant when the cardiology patients were removed from the comparison. There was no significant difference in sex ratio, two thirds being male in both groups. The non-organic patients had had more years of education than the organic patients (difference = 0.65 yr, 95% CI 0.15~~1.15). When the male patients were classified into occupational groups (professional. skilled and unskilled), no significant difference was found between non-organic and organic groups (3 x 2 chi square test). A breakdown of the non-organic patients into constituent groups is given in Table I. The three ‘other psychiatric’ patients received diagnoses (made by the physicians) of enuresis, sexual problem and conversion hysteria.
Numhrrs
of BSI
spp
tom
It can be seen from Table I that all diagnostic groups reported a mean number of BSI symptoms considerably in excess of the student comparison group. Patients receiving a diagnosis of anxiety or of depression had a higher mean number of somatic symptoms than the ‘functional’ group. The ‘no diagnosis’ group had a similar mean number of symptoms to the functional group. The 45 patients diagnosed by the physicians as anxious or depressed were treated as a single ‘mood-disordered’ group and their mean number of somatic symptoms was compared with the organic patient groups. The mood-disordered patients had significantly higher numbers of BSI symptoms compared with all 397 organic patients (difference between means = 4.07. 95% Cl I. 1776.97). The mood-disordered group also had significantly higher numbers of symptoms than each specialty group of organic patients except cardiology. Among the non-organic patients, the mood-disordered group reported a larger number of BSI symptoms than the no-diagnosis group (difference between means = 4.19, 95% CI 0.8997.50). The difference between the mood-disordered and functional patients just failed to reach statistical significance (difference between means = 3.72, 95% CT -0.42 to 7.86).
Somatic
BSI symptoms
symptoms
related to sex, age, education
in Pakistan-l.
249
and occupation
Among the whole non-organic group, the mean number of symptoms reported by males was 18.6 and by females 20.6: this difference was not statistically significant. There was no significant correlation (Spearman’s p) between the number of BSI symptoms and age or years of education. Analysis of variance showed no significant difference on numbers of BSI symptoms between the male patients in the professional, skilled and unskilled occupational groups. As regards individual BSI symptoms, two showed a significant positive correlation (p < 0.01) with increasing age (13, 43) and two items showed a significant negative correlation with age (32, 35). With three symptoms there was an inverse correlation with years of education (7, 28, 39). The magnitude of all these correlations never exceeded L-0.25. Comparisons
between non-organic
and student groups
Table II gives the percentage endorsement rate of each BSI symptom in the three non-organic groups and the student comparison group. With the majority of BSI symptoms, the endorsement rate among all the patient groups was significantly higher than among the student group: items are marked ‘N’ where the difference in percentage endorsement failed to reach 95% confidence. Among the three non-organic clinical groups, the differences on most BSI items were not statistically significant using x’ tests (p < 0.05). However, two items (2, 43) were endorsed significantly more often by mood-disordered than functional patients, and eleven items (2, 5, 15, 19, 23, 26, 27, 30, 31, 43, 44) significantly more often by mood-disordered than no-diagnosis patients. One item (38) was endorsed significantly more often by no-diagnosis than functional patients.
DlSCUSSION
The validity of the data in this study hinges on three factors: the care with which each patient completed the BSI in Urdu; the accuracy of the diagnoses made by the physicians; and how representative the sample was of literate attenders. The authors were impressed by the care taken by the patients whom they observed completing the BSI. None of the patients questioned said they had any difficulty with the meaning of the BSI items, although some had to think hard whether or not they had experienced that symptom during the previous month. The circumstances of this study required the utilization of the ‘best available diagnosis’ from the most senior medical person who saw the patient. Usually this was a medical officer with 335 yr of postgraduate experience. Some physicians may have only limited awareness of psychological elements in patients’ presentation. Medical out-patient clinics at the Mayo Hospital are crowded and very busy. It proved impossible to recruit a consecutive sample or a truly random sample of literate attenders. Our sample consisted of between half and a quarter of the total number of literate attenders, depending how one estimates literacy rates in the clinics. Some sampling bias is therefore probable. The principal problem encountered in analyzing the data from this study can be seen clearly in Table I. The mean number of BSI symptoms reported by the
I Severe headaches 2 Stomach fluttering 3 Neck pain or tension 4 Skin burning 5 Head constriction 6 Chest pain 7 Dry mouth X Misty vision 9 Stomach burning I 0 Weakness or aner_eq II Head hot or hurmng I3 Sweating a lot I? Chest prcssurc I4 Abdominal ache I5 Choking sensation 16 Hands or feet pms and needles 17 Total body aches and pains 1X Heat inside body 19 Palpitations 20 Eyes painful or burning 21 lndigcstion 22 Trembling or shaking 23 Urine frequency 74 Low back trouble 2s Stomach swollen or bloated 26 Head heacy 27 Tired all the time ‘8 Leg pain 20 Nausea 30 Head about to burst 31 Breathing difficulty 32 Tingling all over 31 Constipation 34 Boucl frequency 35 Palms sweating 36 Throat lump 37 Giddy or dizzy 7X Bitter taste 3’) Whole body heavy 40 Urine burning 41 Buzzing in ears or head 42 Heart weak or sinking 43 Excessive wind or gas 44 [lands or feet cold ‘N’ denotes
no significant
dilrerence
Mooddisordered N = 45
Functional N = 31
NO diagnosis ‘A’= I24
51 60 73 27 46 66 60 N 51 50 7X 33 31 N 5X 51 49 3’) N 5X 50 XI 36 N 60 3X 64 61 40 61 x0 53 43 h3 38 34 62 24 39 24 56 47 ?I 39 44 66 71 53
4X 37 N 60 30 39 52 52 N 4X 53 71 23 N 30 N 4.5 SO 40 42 N 5X 41 N 6X 42 N 45 N 42 4X 57 26 55 N 61 55 45 5s 3’) 17N 50 23 N 26 N 23 N 52 26 N 29 26 24 N 5x 36 45
37 N 33 61 29 27 5s 54 N 50 3x 71 2Y 25 N 41 49 30 56 so 44 60 3X N 47 N 31 3x 57 35 43 N 60 60 3’) 42 22 29 46 29 30 N I9 3.3 46 33 3X 36 49 39 34
from student
group
Students N = 317 2’)
IX 30 II I4 I5 47 22 I7 40 18 21 I? 2Y 7 33 22 27 30 35 39 I5 ?I 21 7 44 19 33 I6
IY 6 12 17 IO 26 IO 72 IY X II 15 I7 I5 2s
on 1’ test (95’!:, confidence).
‘mood-disordered and functional’, and ‘no diagnosis’ groups of patients is not significantly different from that reported by patients who received diagnoses of gastro-intestinal or cardiological disorders. There are several possible explanations for this lack of difference between the groups. The first possibility is that the BSI items distinguish poorly between symptoms of organic and non-organic origin. It would be a bold claim that a distinction can be made between abdominal pain due to organic and functional causes, likewise certain types of headache.
Somatic
symptoms
in Pakistan-I.
251
The second possibility is that the groups are poorly defined, resulting in many non-organic patients in the organic groups, and vice versa. We have already mentioned those patients who were given a dual diagnosis, psychiatric and physical. Other patients may have been given an apparently ‘physical’ diagnosis like gastritis, which may refer to a functional disturbance. And then there could be straightforward errors in diagnosis which results in patients being assigned to the wrong group. The third possibility is that non-organic symptoms are very common and occur often in patients with physical illness. Of all the persons in Lahore suffering from upper respiratory tract infections, for example, it may be only the more anxious patients who make their way to the Mayo Hospital out-patient department for treatment. The mean number of BSI symptoms reported varies considerably among the medical specialties. It might be surmized that this was related to the number of symptoms in the BSI referring to that specialty. In order to achieve high scores on the BSI, symptoms must be reported from several different body systems. What distinguishes ‘non-organic’ patients (and enables clinicians to recognize such patients) is the fact that they complain of widely differing symptoms which do not add up to any particular physical disease or syndrome. Socid
churacteristics
qf ‘non
-organic’
patients
The socio-demographic characteristics of western patients presenting with somatic symptoms of non-organic origin have been described in several studies. Crandell and Dohrenwend [6] suggested that people of lower social class and poorer education tend to express emotional distress in somatic terms. In an important review ‘Social psychologic factors affecting the presentation of bodily complaints’, Mechanic [7] concludes that patients who express psychological distress through physical language tend to be uneducated or to come from cultural groups where the expression of emotional distress is inhibited. It is often stated that emotionally-disturbed patients of lower social class and limited education in the Indo-Pakistan Subcontinent usually present with somatic symptoms [8,9]. In the present study, it might have been predicted that the non-organic patients would have been of lower social class than patients with organic disease. In fact, the non-organic patients had a higher mean number of years of education than patients receiving a physical diagnosis. Among the non-organic patients there was no significant correlation between education and number of BSI symptoms reported. There are several possible explanations for these results. Patients in this study were selected for their literacy, excluding subjects with low levels of education. The method of recruitment of patients in the clinics may have been subject to other kinds of sampling bias. Moreover patients were asked specifically about symptoms they had experienced: which is a different form of enquiry to previous studies which have focused on a presentation of symptoms by the patient. People are likely to report more symptoms in a paper-and-pencil questionnaire than they will volunteer to doctors, when they select symptoms they regard as indicative of disease or particularly troublesome [lo]. It is possible that the more educated patients may report more symptoms under these circumstances.
D. B. MUMFOKUet al.
252
Inter -relationship
of the non -organic groups
The non-organic patients belong to three groups: mood-disordered, functional and no-diagnosis. It is important to consider how these groups relate to each other, in particular whether functional and no-diagnosis patients are unrecognized mood-disordered patients. As regards mean number of BSI symptoms reported, there was no significant difl‘erence between the three non-organic groups. All three groups reported around twice as many symptoms as the student comparison group. With four items (7, 12. 16, 20) differences in percentage endorsement between students and the mood-disordered group failed to meet the 95% confidence criterion, the same items also failed to meet this criterion (with one exception) in the functional and no-,diagnosis groups. It is noteworthy that the functional group did not have especially high BSI scores. Many of these patients may have had single-system symptoms (for example, only gastro-intestinal symptoms), whereas to obtain high scores on the BSI, multiple somatic symptoms must be reported from different parts of the body. The no-diagnosis group is likely to be a mixed group. Many of these patients reported very few somatic symptoms. It has already been commented that the out-patient facility at the Mayo Hospital is a walk-in clinic. without any screening or selection of patients. This is likely to result in some patients with trivial or minimal symptomatology attending for reassurance or treatment. The patient population may be more similar to that seen by British general practitioners than it is to attenders at British hospital out-patient clinics. Although the three non-organic groups were similar in the reporting of somatic symptoms. the mood-disordered group appears to be the most unlike the student comparison group. If identification of any group of non-organic patients is possible on the basis of particular somatic symptoms. it is likely to be this mood-disordered group. The selection of the BSI items which discriminated best between organic and mood-disordered patients, and the evaluation of different versions of the BSI to screen for mood disorders. forms the sub.ject of the second paper. REFERENCES MACDO%ALI) AJ. BOUCHIEK IAD. Non-organic gastrointestinal illness: a medical and psychiatric study. Br J I%j~/zitrt 1980; 136: 376 283. GOLUWKG DP. Identifying psychiatric illness among general medical patients. Br .Vrd J 1985: 291: 161 162. TwwK P. T/W R& of B&;/V F’cL~~~.Fin Ati.ri~j,. Maudslcy Monograph 73. Oxford: OUP. 1976. Muhwotw DB, Bnv~x;ro~ JT. BHATNAGAK KS, IILTSAIV Y, MIKZA S. NARAGHI MM. The Bradford Somatic Inventory: a multi-ethnic inventory ofsomatic symptoms reported by anxious and depressed patients in Britain and the Indo-Pakistan Subcontinent. Br J P.vdric~ 1991: (in press). KLEIFWANA. Anthropology and psychiatry: the role of culture in crowcultural research on illness. Br J Prwhiu/ 1987; 151: 447~454. CKAN&LI. DL., DOHKI:NWFNIIBP. Some relations among psychiatric symptoms. orgamc illness and social class. Am J P.v~rhitrt 1967; 123: 1527 1538. MECHANIC.D. Soci:tl ,sychologic factors affecting the presentation of bodily complaints. NCW Dig J ~Cfcd 1972; 286: I I32 I 119. PKAKASH R, SFTHIBB. Hypochondriacal symptoms in mcdlcal patients and their psychiatric statuy. /,lrlic/rr J P.\,vC/ritrr 1978; 20: 240 243. JASAI(IKIMAIAH N, SUHBAKKISH?ADK. Somatic neurosis in muslim women m India. SW P.\j~/zinr 19x0: 15: 103 206. MC ~FOKI> DR. Somatic sensations and ps~~chological distress among students in Britain and Pakistan. SW P.s)~/~itrt f?j~hitrr Qiclwriol 19X9: 24: 321 ~324.
Somatic
symptoms
253
in Pakistan-I.
APPENDIX
B.S.I. 2-1
B-FORD
SOMATIC
NAME -------------
SEX -_-
INVENTORY
AGE _--
STUDY No_____-
We should like to know if you have had any body symptoms over the past month. Please answer all the questions simply by ticking the appropriate box. Remember that we want to know about the past month, not symptoms you have had before that. It is important that you try to answer all the questions. Thank you very much for your co-operation. Present on LESS than 15 days in ” During the past month
. . . . ‘*
1
Have you had severe headaches 3
2
Have you had fluttering orafeeling of something moving in your stomach 7 Have you had pain or tension in your neck and shoulders 7 Has your skin been burning or itching all over 3 Have you had a feeling of constriction of your head, as if it was being gripped tightly from outside 7 Have you felt pain in the chest or heart 7 Has your mouth or throat felt dry 7 Has there been darkness or mist in front of your eyes? Have you felt a burning sensation in your stomach 7 Have you felt a lack of energy (weakness) much of the time 7 Has your head felt hot or burning 7 Have you been sweating a lot 7 Have you felt as if there was pressure or tightness on your chest or heart 7
4
Have you been suffering ache or discomfort in the abdomen 7
5
Has there been a choking sensation in your throat 7
Absent
past month
Present on MORE than 15 days in past month
q q
q q
q q
q cl
q q
q q
q 0 q q cl q 0 cl
q q q q q q q q
q q q q q q cl q
q q q
q cl q
cl q q
D.
254
** During
the past month
B. MUMFORD et al.
. . . . *’
16
Have your hands or feet had pins and needles or gone numb?
17
Have you felt aches or pains all over the body 7
16
Have you had a feeling of heat inside your body 7
19
Have you been aware of palpitations (heart pounding)?
20
Have you felt pain or burning in your eyes 7
21
Have you suffered from indigestion 7
22
Have you been trembling or shaking 7
23
Have you been passing urine more frequently ?
24
Have you been having low back trouble 7
25
Has your stomach felt swollen or bloated ?
26
Has your head felt heavy 7
27
Have you been feeling tired, even when you are not working?
26
Have you been getting pain in your legs 7
29
Have you been feeling sick In the stomach (nausea)?
30
Have you had a feeling of pressure inside your head, as if yaur was going to burst ?
head
31
Have you had difficulty In breathing, even when resting?
32
Have you felt tingling (pins and needles) all over the body?
33
Have you been troubled by constipation ?
34
Have you wanted to open your bowels (go to the toilet) more often than usual ?
35
Have your palms been sweating a lot 7
36
Have you had difficulty in swallowing, as if there was a lump in your throat 7
37
Have you been feeling giddy or dizzy 7
38
Have you had a bitter taste in your mouth 7
39
Has your whole body felt heavy ?
40
Have you had a burning sensation when passing urine?
Absent
Present on LESS than 15 days In past month
q q q q q q q q cl Cl q q q q 0
q q cl q q q q 0 q q q q cl q Cl
q q q
q cl q
q q
q q
q q q q q
q q q q q
Present on MORE thar 15 days In past montt
Somatic
”
During
the
past month
symptoms in Pakistan-I.
.... ”
255
Absent
41
Have you been hearing a buzzing noise in your ears or head?
cl
42
Has your heart felt weak or sinking 7
cl
43
Have you suffered from excessive wind (gas) or belching 7
cl
44
Have your hands or feet felt cold 7
cl
Present on LESS than 15 days in past month
cl q 0 Cl
Present on MORE than 15 days in past month
a q cl q
