GAS SYNDROME

The term “culture” is a keystone in psychiatry. Culture refers to the shared patterns of feelings,
beliefs and behaviour that reflect in the way of living in a society. Cultural factors influence
understanding, presentation, diagnosis, management, course and outcome of many diseases,
especially psychiatric disorders.1 Culture is also best conceptualized as a totality, composed of a
complex system of symbols possessing subjective dimensions such as values, feelings, and ideals
and objective dimensions including beliefs, traditions, and behavioral prescriptions, articulated
into laws and rituals.2
Culture uniquely influences mental health of people living in a given society. Mental health
problems from presentation of illness to course and outcome, at every stage are influenced by
cultural issues. Large numbers of patients get referred to the physician or psychiatrist of their
cultural milieu as he/she can understand the patient and his psyche due to the understanding of
cultural factors which influence the disease and healing process.3
Every culture provides explanations and causal attributions for somatic symptoms. These
explanations, in turn, set up expectations that influence the ways that individuals attend to their
bodies and the sort of symptoms they recognize and report to others. The prevalence of
explanatory models and prototypes may also influence the prevalence of specific clinical
presentations of symptoms and syndromes.4 Depending on circumstances, these symptoms can be
seen as an index of disease or disorder, an indication of psychopathology, a symbolic
condensation of intra-psychic conflict, a culturally coded expression of distress, a medium for
expressing social discontent, and a mechanism through which patients attempt to reposition
themselves within their local worlds.5

The term ‘cultural concept of distress’ is a new addition to the Diagnostic and Statistical Manual
of Mental Disorders (DSM) series with the publication of DSM-5: ‘Cultural Concepts of
Distress (CCD) refers to ways that cultural groups experience, understand, and communicate
suffering, behavioral problems, or troubling thoughts and emotions’.6
There are several well established culture bound syndromes and many new are emerging but
research on this area is scarce. Gas has been a frequent presenting complaint in this sub-
continent. A medical school mnemonic for ten causes of abdominal distension are (10 F’s) -food,
fat, flab, fluid, flatus, feces, fetus, factitious, fatal, and functional. ‘Functional’ indicates
psychological causation.7
The largest case series of functional abdominal bloating was by Alvarez’s titled “hysterical type
of nongaseous abdominal bloating.8
One of the common complaints of persons coming to medical attention is ‘Gas’ or similar
terminologies like ‘vayu’ etc. People attribute varied symptoms from abdominal discomfort,
chest pain, headache, joint pains, back pain, somatic complaints to ‘Gas’. ‘Gas’ is reported to be
the cause for the distress in patients and the primary duty of the treating clinician is to relieve
them of the gas. They consult doctors from all systems of medicine and specialists of all
branches. Gas can really be a difficult symptom to handle and many reach psychiatrists.9 The
problem of troubling Gas or vayu has been influencing Indian culture/tradition since ancient
days. Charaka Samhita deals with medical diagnoses and treatment. The Charaka described the
human body as being an aggregate volume of cells where growth depends on Karma, Vayu (air
or bioenergy) and Svabhava (personal nature). As Ayurveda has great influence on Indian people
and beliefs, it says, there are five Vayu deities, Prana, Apana, Vyana, Udana, and Samana, which
control life (and the vital breath), the wind, touch/sensation, digestion, and excretion, which may
be one of the reasons for the wide range of symptom attribution to Gas.10
In two large population surveys bloating correlated with psychiatric dysfunction: depression,
sleeping difficulties, problems of coping, panic disorder, and agoraphobia.11, 12
Psychosocial morbidities are associated with increased levels of gastrointestinal symptoms in
general. Depression and somatization levels were associated specifically with increased
postprandial symptoms.13
Patient Health Questionnaire (PHQ) -15 has a question on nausea, gas and indigestion. 14
Research into bloating and distension has been sparse. In the past, it was always considered that
the terms bloating and distension both describe the same phenomenon. However, more recently,
it has become apparent that not all individuals who feel bloated necessarily exhibit an increase in
abdominal girth. This has led to the proposal that the term bloating should be used to describe the
sensation of increased abdominal pressure and distension should only be used when there is an
actual change in abdominal circumference.15
Gautam et al in his study in north Indian population, reported that the predominant somatic
complaint in patients attending a General Hospital Mental Health Unit was constipation and
feeling of gas in the abdomen.3 Govind Bang observed certain group of patients who presented
with alternations in behaviour and experience characterized by marked somatic symptom
configuration attributed their problem to Gas.16 In a study by Ghosh in 2006, done in specialist
clinic, the commonest presenting unexplained somatic symptoms were so-called "gas", "acidity"
and "dysentery" expressed in vernacular terms. Many of whom had underlying depression and
anxiety.17 In a cross sectional observational study done in Southern India by Manoj Shettar et al;
examining 105 consecutive patients who were diagnosed with somatization disorder or
undifferentiated somatoform disorders with no psychiatric co-morbidities other than tobacco
dependence seeking outpatient over a period of one year using PHQ-15 found that the most
common presenting complaints were pain in arms, legs, or joints (91.4%), back pain (84.8%),
feeling tired or having low energy (83.8%) and nausea, gas or indigestion (81.0%). Gas
complaints were more common in men compared to women.18

The Cultural Concepts of disease (CCD) literature demonstrates an overlap with psychiatric
disorders as well as identification of populations with emotional, behavioral, or cognitive
problems with significant impairment that may not be captured by psychiatric diagnoses. The
single summary effect with low heterogeneity in their analyses was the comparison of CCD and
general psychological distress: persons with any CCD have five-fold greater odds of having
general psychological distress than persons not endorsing CCD. Furthermore, in order for global
mental health not to be limited to treating only disorders recognized by Western biomedical
psychiatry, it will be crucial to consider how scaling up services can also address CCD.
(Brandon) There needs to be increased research in Culture bound syndromes.6
We do see a significant proportion of patients visiting varied specialists attributing all their
problems to Gas. The difference in the understanding and beliefs of the illness between the
clinician and patient can result in inapproprite assessment or dis-satisfaction. If the clinician’s do
not understand a patient’s traditional health beliefs they may not accept the treatment or become
non-compliant with the treatment.
Treatment
Psychological: Psychoeducation, Reassurance to the patient, supportive psychotherapy,
psychotherapy to alleviate underlying stress.

Pharmacological: Treat the underlying psychiatry illness. Antianxiety drugs and antidepressants
generally help.

REFERENCES

1. Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J

Psychiatry. 2007; 49(3):208–210.
2. Trujillo M. Culture and organization of psychiatric case. Psychiatr Clin North Am. 2001;
24(3):539–52.
3. Gautam S, Jain N. Indian culture and psychiatry. Indian J Psychiatry. 2010; 52(Suppl
1):S309-313.
4. Kirmayer LJ, Sartorius N. Cultural Models and Somatic Syndromes. Psychosom
Med. 2007; 69:832-840.

5. Kirmayer LJ, Young A. Culture and Somatization: clinical, epidemiological, and

ethnographic perspectives. Psychosom Med. 1998; 60(4):420-430.

6. Brandon AK, Rasmussen A, Kaiser BN, Haroz EE, Maharjan SM, Mutamba BB, Joop
TVM de Jong, Hinton DE. Cultural concepts of distress and psychiatric disorders:
Literature review and research recommendations for global mental health epidemiology.
International Journal of Epidemiology, 2014; 43(2):365–406.

7. Sullivan NS. Functional abdominal bloating with distention. International Scholarly

Research Notices. 2012. Article ID 721820, 5 pages.
8. Alvarez WC. “Hysterical type of nongaseous abdominal bloating,” Archives of Internal
Medicine.1949; 84: 217–245.

9. Kakunje A, Puthran S, Shihabuddeen ITM, Chandran MVV. ‘Gas Syndrome’ - A Culture

Bound Syndrome. Online J Health Allied Scs. 2013; 12 (4):9.
10. Avasthi A, Kate N, Grover S. Indianization of psychiatry utilizing Indian mental
concepts. Indian J Psychiatry. 2013; 55(6):136-144.
11. Johnsen R, Jacobsen BK, Forde OH. Associations between symptoms of irritable colon
and psychological and social conditions and lifestyle. BMJ, 1986. 292; 6536: 1633–1635
12. Walker EA, Katon WJ, Jemelka RP, Roy-Byrne PP. Comorbidity of gastrointestinal
complaints, depression, and anxiety in the Epidemiologic Catchment Area (ECA)
Study. American J Medicine. 1992, 92: S26–S30.

13. Oudenhove LV , Tornblom H, Storsrud S,Tack J, Simren M. Depression and

Somatization are Associated with Increased Postprandial Symptoms in Patients with
Irritable Bowel Syndrome. Gastroenterology, 2016; 150: 866–874.

14. Kocalevent RD, Hinz A, Brahler E. Standardization of a screening instrument (PHQ-15)

for somatization syndromes in the general population. BMC Psychiatry. 2013; 13: 91

15. Agrawal A, Whorwell PJ. Abdominal bloating and distension in functional

gastrointestinal disorders – epidemiology and exploration of possible mechanisms.
Alimentary Pharmacology & Therapeutics. 2008; 27: 2-10

16. Bang G. Indian Psychiatric Society. Abstracts of 59th Annual National Conference of
Indian Psychiatric Society. Indian J Psychiatry 2007; 49:1-60.

17. Ghosh JM. Unexplained somatic symptoms- Diagnostic window for mental disorders. J
Indian Med Assoc. 2006; 104 (5):255-260.

18. Shettar M, Kakunje A, Chandran M, Mendonsa RD, Karkal R. Presenting Complaints in

Somatoform Disorders: A Hospital Based South Indian Study. National Journal of
Medical and Dental Research, 2017; 5(2): 106-111.