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Newark, NJ
Dr. Lavietes is Associate Professor of Medicine, the New Jersey Medical School.
Correspondence to: Marc H. Lavietes, MD, FCCP. UMD-NJ Medical School I-354, 100 Bergen St, Newark, NJ 07103-2406; e-mail: lavietmh{at}umdnj.edu
As physicians, we are taught early in our careers that our initial medical history and physical examination provide our most important diagnostic information. Laboratory data follow. They serve both to confirm our diagnostic impressions and to quantify the extent of the disease state. Surveys12 of asthmatic patients, however, have demonstrated that it is very difficult to ascertain the severity of a person’s illness from a verbal description of symptoms. Further observations in asthmatic subjects indicate that our patients’ personalities influence the magnitude or intensity of the symptoms they associate with their asthma. Asthmatic patients who score high on either the hypochondriasis or somatization scales, for example, report high levels of dyspnea to be associated with only mild or moderate degrees of airway dysfunction, either during an attack or when stable.34 By contrast, those patients scoring low on these scales tend to minimize the discomfort they associate with severe airway obstruction. Thus, the examining physician may gain some insight into the degree of airway dysfunction in asthmatic patients from their verbal history only if the physician is able to factor a sense of the patient’s tendency to exaggerate or minimize symptoms into the clinical assessment.
Other studies in the literature have attempted to judge whether or not there are diagnostic clues in the language patients choose to describe their dyspnea or the discomfort they associate with breathing. Mahler et al5 have explored the language that patients with seven different disease states (eg, asthma, congestive heart failure, interstitial lung disease) use to describe their dyspnea. These authors presented their subjects with a list of 15 descriptors. The investigators then asked each patient to walk along a hospital corridor until he felt an intensity of dyspnea equal to a grade of 3, or moderate, on the Borg scale. Patients were then asked to select those descriptors that best characterized their discomfort after the walk. Of interest, only patients with diagnoses associated with airway obstruction (eg, asthma and cystic fibrosis but not COPD) chose terms that imply tightness, such as "tight" or "constricted," to describe their discomfort. Other terms, such as "work" or "inhalation" were not specific for any diagnostic category. This may make sense from the point of view of the pathophysiology in that asthma and cystic fibrosis, unlike any of the other diagnostic categories, are associated with edema, inflammation, and muscular constriction of the larger airways. The feeling of tightness may be a feeling generated by the stimulation of airway afferents, a physiologic event shared by, and specific to, these two disease entities. A criticism of the work of Mahler et al5 is, however, that their subjects were asked to choose their words from a list of descriptors that were given to them. In this author’s experience, when patients with asthma are asked to describe their dyspnea using their own words, very few will volunteer a descriptor similar to those given by Mahler et al. Invariably, however, the few patients who do volunteer the word "tight" will have asthma, and the few who volunteer "I can’t breathe in" will have interstitial lung disease or pulmonary emboli. It appears, then, that there is some link between the pathophysiology of a disease and the words that patients choose to describe their discomfort. The fact that very few subjects will use these words, however, should send us another message: that is, it is not reasonable to expect all people, even if they speak the same language, to link the same word or descriptor to a given sensation.
In this issue of CHEST (see page 1942), Han et al have explored another dimension of the question of whether or not the language used to describe dyspnea will provide diagnostic clues. They have examined the possibility that the relationships among illness, the symptoms associated with an illness, and the language used by a patient to describe the illness may differ between patients of different cultures. They are not the first authors to explore this possibility. They have cited two earlier studies on this subject, one of which involved both African Americans and whites, and the other involving Thai children. The study by Han et al is, however, extensive and elegant. The authors have meticulously developed a list of 61 potential descriptors of symptoms that are associated with pulmonary diseases and have administered this list to a total of 328 subjects (232 patients and 96 control subjects). From these responses, the authors have reduced the 61 descriptors to a list of eight factors, which are analogous to the clusters developed by Mahler et al.5
The most interesting finding by Han et al involves their factor called "dyspnea-affective aspect." This factor is composed both of symptoms that are ordinarily associated with chest disease (eg, tightness) and other symptoms that are usually associated with nonorganic disease (eg, a lump in the throat). This factor is linked to two disparate patient groups: first, those with medically unexplained illness; and second, those with asthma. The authors note that while Western persons would associate feelings such as sadness or lethargy with conditions such as depression, for example, Chinese people would use a descriptor associated with anatomy to describe those same feelings. Chinese people do not view emotional disturbance as illness and therefore describe the feelings Westerners would associate with emotional illness in terms of bodily sensations. In the Chinese culture, the feelings associated with both asthma and unexplained illness are described as "something pressing into the chest." This reluctance in the Chinese culture to identify unexplained illness as physiologic illness explains why persons with medically unexplained illness describe their discomfort as "tightness."
Of interest is the fact that in both cultures there seems to be some link between the language used to describe asthma and the words used to describe unexplained illness. In Western culture, asthmatic patients are seen as existing on a continuum in which some of the patients describe an intensity of symptoms that seems to be out of proportion to the extent of their airway obstruction. By contrast, Chinese culture sees two distinct patient groups. In both cultures, there appears to be a link between asthmatic patients and patients with unexplained illness. While the language used to describe asthma may differ between cultures, one can only wonder whether or not the Chinese patients categorized as having unexplained illness who describe their feelings as "tightness" are the same patients as the Western patients with mild asthma who rate their dyspnea as intense and score highly on a somatization scale.
Given the current state of knowledge, it is important for the physician to recognize the possibility that patients of different cultural backgrounds may describe their illnesses differently. Information as to "what cultures," "what diseases," and "what specific adjectives" is, at present however, lacking.
References
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