Psychological morbidity in primary health care in Oman MEDICAL SCIENCES (2000), 2, 105–110 © 2000 SULTAN QABOOS UNIVERSITY 1Department of Medicine, 2Department of Obstetrics and Gynaecology, 3Department of Behavioural Medicine, 4Department of Family & Community Health, College of Medicine, Sultan Qaboos University, P O Box 35, Al-Khod, Muscat 123, Sultanate of Oman. *To whom correspondence should be addressed. E-mail: adawi@squ.edu.om 105 Psychological morbidity in primary health care in Oman a preliminary study Al-Lawati J1, Al-Lawati N2, Al-Siddiqui M1, Antony S X3, Al-Naamani A3, Martin R G3, Kolbe R4, Theodorsson T4, Osman Y4, Al-Hussaini A A3, *Al-Adawi S3 عمان في أألولية الصحية الرعاية في النفسية المراضة مارتن، روجرالنعماني، عزيز أنتوني، سجيفالصديقي، مزون اللواتيا، نواراللواتيا،جليلة العدوي وسمير الحسيني الدين عالء عثمان، يوسف ثيودورسون، ورت آولبي، الفر مؤشرات بين التوافق وفحص عمان، في أألولية الصحية الرعاية مراآز في النفسية والمراضة يدالتجس أنتشار مدى تقييم إلى البحث يهدف :الهدف: الملخص الجسمي برادفورد مقياس أستخدم. عمان في أألولية الرعاية مراآز راجعوا ممن متتابعين مريض 100 مسح تم :الطريقة. النفسية وأألضطرابات التجسيد برادفورد عرفها آما التجسيد تاأضطراب بان الدراسة أظهرت :النتائج .النفسي الكرب لقياس ذاتي اقرار انوأستبي النفسجسمية، المراضة يقيس والذي يعاني ::الخالصة. النفسية والمراضة التجسيد مؤشرات بين احصائيا مهم ايجابي ترابط وظهر أألولية، الصحية الرعاية مرضى بين شائعة النفسية والمراضة في المرضى بأن القديمة الفكرة الدراسة هذه نتائج تتحدى .والجسماني النفسي الكرب من أألولية الصحية رعايةزالآين يراجعون مرا الذ العمانيون المرضى .فقط جسماني شكل على فيهم الكرب يظهر النامية الدول ABSTRACT: Objective – To assess the prevalence of somatization and psychological morbidity presenting to primary health care in Oman and to examine the correlation between the indices of somatization and psychological disorders. Method – Consecutive primary care patients (n = 100) were screened with Bradford Somatic Inventory which gauges psychosomatic morbidity, and Self Reporting Questionnaire, which measures psychological distress. Result – Somatization disorder as defined by Bradford, and psychological morbidity were relatively common in primary care settings. There was significant positive correlation between indices of somatization and psychological morbidity. Conclusion – Omani patients seeking primary health care equally experience both psychological distress as well as somatic ones. This finding challenges the old notion that people in developing countries generally express distress somatically. KEY WORDS: somatization, cross-cultural, psychological distresses, primary-health care, Oman octors often meet patients who insist they are diseased despite repeated assurances to the con- trary. Such patients who frequently seek care in primary as well as tertiary medical settings, and account for a large number of consultations, �doctor shopping�, unnecessary tests and multiple surgeries, cause what is sometimes called �fat file syndrome�.1 Patients, in their turn, come to believe that they receive neither clear diag- nosis nor effective treatment.1,2 Since doctors tend to pre- scribe medication symptomatically, iatrogenic illnesses might ultimately result.3,4 Although it is possible that such patients might be suffering from unidentifiable physical illnesses,5�7 empiri- cal evidence suggests that they might be somatizing.8 As a clinical entity, somatization is a chronic, disabling syn- drome that presents a physical facade hiding significant psychopathology. Somatic symptoms are common in af- fective and anxiety disorders.9,10 It is usually assumed that somatization occurs in response to psychological stresses on a background of predisposing personality factors, but in adopting the sick role, psychological equilibrium is achieved. Clinical and epidemiological surveys over the past two decades suggest that acute forms of somatoform disorders are invariably present in all primary care settings.11�14 Naturalistic observations of somatization disorders have revealed that the condition begins before age 30, and most often during teenage. The disorder is inversely related to social position, occurs most often in communities with little urbanisation and literacy, and affects more women than men.15,16 Using screening instruments thought to be sensitive to local idioms of emotional distress, Ohaeri & Odejide17 and Mumford et al18 have found the incidence of psycho- logical morbidity to range from 20% to 80% in various cultures among the developing countries. Complementing D A L - L A W A T I E T A L 106 surveys from developing countries, Goldberg and Black- well19 in UK, Giel & Le Nobel20 in the Netherlands, and Katon et al3 in USA found similar patterns. The frequent association of somatization and affective disorders sug- gests that the latter is a predisposing factor and not sim- ply a reaction to disability.21 In the Arab world, El-Rufaie et al22 and AlSubaie et al23 have reported high incidences of patients complain- ing of depression and anxiety and a variety of somatic symptoms, confirming previous anecdotal reports.24�26 However, these reports have relied on clinical impression and psychological scales that lack items to elicit somatic symptoms.8 Since various commentators in the field have suggested that non-western patients tend to use �somatopsychic� idiom of distress rather than verbalize their distress in psychological concepts,27�29 it remains to be established whether Omanis, Arab/Muslim, follow this generalization. The world over, psychological morbidity has been found to be very high among patients seeking primary healthcare.14,30 In Oman, such research has not been con- ducted despite the nearly 12 million visits per year to pri- mary healthcare facilities, representing an average of 5.4 visits per year per person, in a population of slightly above two million.31 The interrelated aims of this study are to (a) deter- mine the rate of psychological morbidity among Omani patients attending primary health care in Muscat urban conglomeration, the national capital region of Oman, (b) determine the prevalence of somatization in those pa- tients and (c) explore whether there is a relationship be- tween psychological distress and somatization. METHOD This research forms part of the studies conducted at the Department of Behavioural Medicine, College of Medicine, Sultan Qaboos University, with the aims to examine the rate of psychological disorders in Oman. The study was conducted in the newly built Bowsher Health Care Centre, serving mostly residents of suburban areas of Muscat. SUBJECTS This is a prospective, cross-sectional, study drawn from patients attending in a polyclinic for both male and female Outpatient care. Consecutive patients, 52 females and 48 males, who were able to speak Arabic and attend- ing the clinics on a self-initiated visit for a new problem, were invited to participate in the study. Patients known to have sensory or cognitive impairments that would affect proper completion of the study questionnaires were ex- cluded from the sample. All subjects were able to speak Arabic. A brief ex- planation of the study was given to the patients and their oral consent taken. Some degree of privacy for the sub- jects was attempted whilst administering the question- naires. ASSESSMENT Experienced staff members had produced Arabic- language versions of the questionnaires by the method of back-translation.32 In the pilot phase, interviewers (7th year medical students) were trained to reliably read out the items of the questionnaire in the local dialect of spo- ken Arabic, and rate the patients� responses accordingly. In order to accommodate for illiteracy among some sub- jects, questions were read to all the patients. As a result, there was substantial inter-rater agreement on the various items of the questionnaires. SOMATIZATION Bradford Somatic Inventory (BSI)8 is a 44-item in- ventory for psychosomatically expressed psychological distress. It has cross-cultural validity as shown by studies carried out in Great Britain, Pakistan, India, Nepal, and Russia.18,33 The BSI asks the subject on a wide range of somatic symptoms during the previous month, and whether or not the subject has experienced a particular symptom, on more or fewer than 15 days during the month (scoring 1 or 2 respectively). For the present pur- pose, the scoring was based on Mumford,18 where a score >40 is considered to be the �high� range, 26�40, �middle� range and 0�25, �low� range. PSYCHOLOGICAL MORBIDITY Psychological morbidity was assessed using Self- Reporting Questionnaire (SRQ),30 consisting of 24 short questions concerning key phenomena related to mental disorders. The SRQ requires only a simple �yes� or �no� answer to each question. SRQ has been established to be a psychiatric case-finding instrument for detection of psychiatric patients among visitors of health care facili- ties23 and most of its questions had been selected from existing psychiatric questionnaires such as the Symptom Sign Inventory,34 the General Health Questionnaire35 and the Present State Examination.36 Designed by the World Health Organisation, SRQ has been validated in various developing countries23,30,37 to determine the prevalence of �conspicuous psychiatric morbidity� (CPM), without spe- cific diagnoses.38 For the present analysis, the scores were categorised as follows: high range = 10�20; middle range = 6�9; lower range = 0�5. RESULTS SOCIO-DEMOGRAPHIC FEATURES The interview sample consisted of 100 patients with a mean age of 26.03 ± 9.62, (52 females with mean age 25.65 ± 10.48 and 48 males with mean age 26.44 ± 8.68). There was no statistically significant age difference be- tween males and females (t = 0.41, df = 96.89, p > 0.05). P S Y C H O L O G I C A L M O R B I D I T Y I N P R I M A R Y H E A L T H C A R E 107 Of the patients, 54% were single; 41% married and the remainder (5%) either divorced or widowed. As re- gards education, 7% each had university degrees 7% or professional diplomas, 39% had secondary school educa- tion, 34% primary education and 13% were illiterate, ex- cept one patient who had a cursory knowledge of Koran. While 42% were working, 15% were unemployed, 20% were students and 24% were housewives. The patients complained of the following types of illnesses: musculoskeletal (23%), gastrointestinal (17%), respiratory (17%) cardiovascular (16%), genitourinary (10%), central nervous system (8%), and infectious (5%). PREVALENCE OF SOMATIZATION Using cut-off points of 40 and above as �high� , 26� 40 as �middle� and 0�25 �low� range, Figure 1 shows the percentage scores on BSI of whole sample as well as for males and females separately. 7% of the sample scored �high�, among whom there were more females (9.6%) than males (4.2%). 16% of the whole sample scored in the �middle� range. Again females (21%) outnumbered the males (10.5%). The bulk of the subjects (77%) were in the �low� range. Here males (88%) outnumbered females (68%). In terms of gender differences, women showed a trend towards somatization (χ2, p = 0.05). FIGURE 1. Performance on Bradford Somatic Inventory PREVALENCE OF PSYCHOLOGICAL DISORDERS Using a cut-off point of 10�20 as �high� range, 6�9 as �middle� range and 0-5 as �lower� range, Figure 2 shows the percentage scores of SRQ for the whole sample, male and female patients. 18% of total sample scored in the �high� range, 14% in the �middle� and 48% in the �lower� range. This means 32% were in psychiatric caseness. Among females, 15% were in the �high� range, 11% in the �middle� range and 20% in the �lower� range. Among males, the figures were respectively 3%, 3% and 28%. In terms of gender differences, women appeared to have a higher propensity towards psychological distress (χ2, p<0.0001). FIGURE 2. Performance on Self-Reporting Questionnaire RELATIONSHIP BETWEEN PSYCHOLOGICAL AND SOMATIZATION INDICES The association between the SRQ and BSI were ex- plored using bivariate correlation. The result shows a sig- nificant inverse correlation between somatization and psycho logic indices (r = 0 .77, p <0.001, n = 76). DISCUSSION The principal aim of this study was to assess the prevalence of somatization and psychiatric morbidity in patients seeking treatment in a typical urban primary health care centre. The study also aimed to be a pilot- screening instrument with multicultural validity. The study found that somatization (as defined by Bradford Somatic Inventory) was present in 17% patient sample, a trend similar to those reported elsewhere.39,40 It is often reported that women are more susceptible to somatization than men, no matter where these studies are conducted.41 Prima facie, our present finding substanti- ates such view. However, this difference could also be due to the manner in which either sex responded to the screening questionnaires, as suggested by other research- ers.42,43 Future studies need to examine how gender shapes responses. 0 10 20 30 40 50 60 70 80 90 High range Middle Range Low range P er ce nt ag e sc or e Total Female Male 0 10 20 30 40 50 60 70 80 90 High range Middle Range Low range P er ce nt ag e sc or e Total Female Male A L - L A W A T I E T A L 108 In conjunction with the rate of somatic syndromes, this study also explored psychological morbidity using WHO�s screening scale, Self-Reporting Questionnaires. It was found that 32% of the sample was identified as psy- chiatric cases, a finding compatible with the earlier stud- ies23 suggesting a high incidence of psychiatric morbidity in patients seeking treatment in primary health care. Again, women were the majority with the tendency to- wards conspicuous psychiatric disturbances. It has generally been assumed that somatization is a subjective state, disguising distress in psychological idiom. Such conceptualisation has been an integral part of the theoretical model of somatization.44,45 From this perspec- tive, an inverse relationship between the indices of soma- tization and psychiatric morbidity should be expected. Contrary to this, the present data suggests a significant and positive relationship between the indices of somati- zation and psychiatric morbidity and close association exists between the somatic and psychological scales, i.e., both scales are possibly measuring similar dimensions of emotional distress and psychological pathology.46,47 Mum- ford et al48 have suggested that somatic and psychological symptoms are �two sides of the same coin of dysphoria� and therefore it is viable to use either somatic or psycho- logical items to screen for psychiatric morbidity depend- ing on local idioms of emotional distress. Alternatively, the situation in Oman may be parallel to those in the other developing countries where improved education has coincided with reduction of somatization.49 In the past decades, Oman has drastically improved education. However, it remains to be established whether rapid ac- culturation has affected how Omanis verbalise their emo- tional distress. The limitation of this study was that it was con- ducted in a cultural setting where research is not usual and among patients who are not often studied. Indeed, it is difficult to show how representative is this patient sample of the general population in Oman; for example, �doctor-shoppers� might have been over-represented. Secondly, the design of this study did not take into ac- count the prevalence of major mental illnesses and did not obtain qualitative data that might shed light on the reasons for the patterns we observed. Thirdly, it is possi- ble that some of these patients were suffering from some hitherto unsuspected physical disturbances, rather than presenting merely depression or anxiety.50�52 Therefore, before one can regard the symptoms as index of psychic distress, one needs to rule out myriads of other possibili- ties including Whitlock�s53 notion that manifestation of acute somatization is built into the central nervous system in order to protect it from overwhelming stress. Lastly, the present study relied on questionnaires. Although questionnaires are easy to apply, they might also elicit in- flated number of positive responses. In a study con- ducted in rural Ethiopia, Korthmann36 noted that the participants often confused simple �yes� or �no� answer to each question on SRQ. Although both BSI and SRI have been previously established to have multicultural valid- ity,8,23,54 one possible way to rule out this problem was to design a two-phase study in order to evaluate both sensi- tivity and specificity of the questionnaires. However, it was not logistically feasible in the present study, which was a �one-shot� design. The study therefore should be viewed as preliminary and with cautions. CONCLUSION The present study suggests that people seeking treatment at primary health care in Oman, especially women, might also be suffering from psychological dis- orders. Inquiring about psychological symptoms in pri- mary health care centres in Oman in patients who present initially with somatic symptoms is worthwhile, in their own language and idioms of distress. Also, screening scales consisting of only somatic symptoms is as effective as psychologically based questionnaires when screening for psychiatric morbidity. The findings of the study also suggest that the generally held view that in non-western countries psychological distress tends to be expressed exclusively in somatic language might not be true. ACKNOWLEDGEMENTS We are grateful to the men and women who volun- tarily acted as subjects for this research. . REFERENCES 1. Kirmayer LJ, Robbins J M. Current Concepts of Somatization: Research and Clinical Perspectives. American Psychiatric Press, Washington 1991. 2. Epstein RM, Quill TE, McWhinney IR. Somatiza- tion reconsidered � incorporating the patient's experi- ence of illness. Arch Intern Med 1999, 159, 215�22. 3. Katon W, Ries RK, Kleinman A. The prevalence of somatization in primary care. Compr Psychiatry 1984, 25, 208�15. 4. Mehl-Madrona LE. Frequent users of rural primary care: comparisons with randomly selected users. J Am Board Fam Pract 1998, 11, 105�15. 5. Simon GE, VonKorff M. Somatization and psychiat- ric disorders in the NIMH epidemiological catchment area study. Am J Psychiatry 1991, 148, 1494�500. 6. Katon WJ, Walker EA. Medically unexplained symp- toms in primary care. J Clin Psychiatry 1998, 59, 15�21. 7. Tokunaga M, Ida I, Higuchi T, Mikuni M. Altera- tions of benzodiazepine receptor binding potential in anxiety and somatoform disorders measured by 123I- iomazenil SPECT. Radiat Med 1997, 3, 163�69. 8. Mumford DB, Bavington JT, Bhatnagar KS, Hus- sain Y, Mirza S, Naraghi MM. The Bradford So- matic Inventory: a multi-ethnic inventory of somatic symptoms reported by anxious and depressed patients in Britain and the Indo-Pakistan subcontinent. Br J Psy- P S Y C H O L O G I C A L M O R B I D I T Y I N P R I M A R Y H E A L T H C A R E 109 chiatry 1991, 158, 379�86. 9. Thurston-Hicks A, Paine S, Hollifield M. Func- tional impairment associated with psychological distress and medical severity in rural primary care patients. Psy- chiatr Serv 1998, 49, 951�55. 10. Escobar JI, Gara, M, Silver RC, Waitzkin H, Holman A, Compton W. Somatization disorder in primary care. Br J Psychiatry 1998, 173, 262�66. 11. Ndetei DM, Muhangi J. The prevalence and clinical presentation of psychiatric illness in a rural setting in Kenya. Br J Psychiatry 1979, 135, 269�72. 12. Giel R, de Arango MV, Hafeiz BA, Bonifacio M, Climent CE, Harding TW, et al. The burden of mental illness on the family. Results of observations in four developing countries. A report from the WHO Collaborative Study on Strategies for Extending Mental Health Care. Acta Psychiatr Scand 1983, 68, 186�201. 13. Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care setting. J Psychosom Res 1988, 32, 137�44. 14. Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural perspective: a World Health Organisation study in primary care. Am J Psy- chiatry 1997, 154, 989�95. 15. Hartung CM, Widiger TA. Gender differences in the diagnosis of mental disorders: conclusions and contro- versies of the DSM-IV. Psychol Bull 1998, 123, 260�78. 16. Desjarlais R, Eisenberg L, Good B, Kleinman A. World Mental Health: Problems and Priorities in Low-Income Countries. Oxford University Press, New York 1995. 17. Ohaeri JU, Odejide OA. Somatization symptoms among patients using primary health care facilities in a rural community in Nigeria. Am J Psychiatry 1994, 151, 728�31. 18. Mumford DB, Saeed K, Ahmad I, Latif S, Mubba- shar M. Stress and psychiatric disorder in rural Punjab: a community survey. Br J Psychiatry 1997, 170, 473�78. 19. Goldberg DP, Blackwell B. Psychiatric illness in gen- eral practices: a detailed study using new methods of identification. BMJ 1970, 2, 439�43. 20. Giel R, Le Nobel CPJ. Neurotic instability in a Dutch village. Acta Psychiatr Scand 1971, 47, 462�72. 21. Cope H, Ron M. Conversion disorders. In: Contempo- rary Behavioural Neurology: M. R. Trimble & J.L. Cum- mings (Eds.) Butterworth-Heinemann, Oxford 1997, pp: 311-�26. 22. El-Rufaie OE, Absood GH, Abou-Saleh MT. The primary care anxiety and depression (PCAD) scale: a culture-oriented screening scale. Acta Psychiatr Scand 1997, 95, 119�24. 23. AlSubaie AS, Mohammed K, Al n Malik, T. The Arabic self-reporting questionnaire (SRQ) as a psychiat- ric screening instrument in medical patients. Annals of Saudi Medicine 1998, 18, 308�10. 24. Hamdi TI, Al-Hasani L, Mahmood A, Al-Husaini A. Hysteria: a large series in Iraq. Br J Psychiatry 1981, 138, 177�78. 25. Racy J. Somatization in Saudi women: a therapeutic challenge. Br J Psychiatry 1980, 137, 212�16. 26. Pu T, Mohamed E, Imam K, El-Roey AM. One hundred cases of hysteria in Eastern Libya�a sociode- mographic study. Br J Psychiatry 1986, 148, 606�9. 27. Leff J. The cross-cultural study of emotions. Cult Med Psychiatry 1977, 1, 317�50. 28. Kleinman A. Anthropology and psychiatry: the role of culture in cross-cultural research on illness. Br J Psychia- try 1987, 151, 447�54. 29. Littlewood R, Lipsedge M. Alien and Alienists. Ethnic Minorities and Psychiatry (2nd Edition). Unwin London. 1989. 30. Harding TW, de Arango MV, Baltazar J, Climent CE, Ibrahim HH, Ladrido-Ignacio L et al. Mental disorders in primary health care: a study of their fre- quency and diagnosis in four developing countries. Psy- chol Med, 1980, 2, 231�41. 31. Directorate General of Planning. Annual Statistical Report. Ministry of Health, Sultanate of Oman 1997. 32. El-Rufaie OEF, Daradkeh TK. Psychiatric screening in primary health care: transcultural application of psy- chiatric instruments. Primary Care Psychiatry 1997 3, 37� 43. 33. Havenaar JM, Poelijoe NW, Kasyanenko AP, Van- den-Bout J, Koeter MW, Filipenko VV. Screening for psychiatric disorders in an area affected by the Chernobyl disaster: The reliability and validity of three psychiatric screening questionnaires in Belarus. Psychol Med 1996, 26, 837�44. 34. Foulds GA, Hope K. Manual of the Symptom Sign Inven- tory (SSI). University of London Press, London 1968. 35. Goldberg DP, Cooper JE, Eastwood MR, Kedward HB, Shephard M. A standardized psychiatric inter- view for use in community surveys. Br J Prev Soc Med 1970, 1, 18�23. 36. Wing JK, Cooper JE, Sartorious N. The Description and Classification of Psychiatric Symptoms: An Introductory Manual of the PSE and CATEGO. Cambridge Univer- sity Press, London 1974. 37. Korthmann F. Problems in practising psychiatry in Ethiopia. Ethiopia Medical Journal 1988, 26, 77�84. 38. Harding TW, Climent CE, Diop M, Giel R, Ibra- him HH, Murthy R S, Suleiman MA, Wig NN. The WHO collaborative study on strategies for extend- ing mental health care, II. The development of new re- search methods. Am J Psychiatry 1983, 140, 1474�80. 39. Bhatt A, Tomerson B, Benjamine S. Transcultural patterns of somatization in primary health care: a pre- liminary report. J Psychosom Res 1989, 33, 671�80. 40. Kisely SR, Goldberg DP. Physical and psychiatric comorbidity in general practice. Br J Psychiatry 1996, 169, 236�42. 41. Keating JJ, Dinan TG, Chua A, Keeling PWN. Hysterical Paralysis. Lancet 1990, 336, 1506�7. 42. Stanfeld SA, Marmot MG. Social class and minor psychiatric disorder in British civil servants: a validated screening survey using the General Health Question- naire. Psychol Med 1992, 22, 739�49. 43. Piccinelli M, Simon G. Gender and cross-cultural dif- ferences in somatic symptoms associated with emo- tional distress. An international study in primary care. Psychol Med 1997, 27, 433�44. A L - L A W A T I E T A L 110 44. Pilowsky I. The concept of abnormal illness behav- iour. Psychosomatics 1990, 31, 207�13. 45. Kellner R. Somatization theories and research. J Nerv Ment Dis 1990, 178, 150�60. 46. Farooq S, Gahir MS, Okyere E, Sheikh AJ, Oye- bode F. Somatization: a transcultural study. J Psychosom Res 1995, 39, 883�8. 47. Hamdi E, Amin Y, Abou-Saleh MT. Performance of the Hamilton Depression Rating Scale in depressed patients in the United Arab Emirates. Acta Psychiatr Scand 1997, 96, 416�23. 48. Mumford DB, Nazir M, Jilani FUM, Baig IY. Stress and psychiatric disorder in the Hindu Kush - a community survey of mountain villages in Chitral, Pakistan. Br J Psychiatry 1996, 168, 299�307. 49. Nandi DN, Banerjee G, Nandi S, Nandi P. Is hys- teria on the wane? A community survey in West Ben- gal, India. Br J Psychiatry 1992, 160, 87�91. 50. Merskey H, Buhrish NA. Hysteria and organic brain disease. Br J Med Psychol 1975, 48, 359�66. 51. Shurbini LA, Ayad FS. Overviews of influences of sociocultural factors on mental illness in Arabic culture. Interdisciplinary Psychological Culture 1997, 29, 70�8. 52. Maier W. Anxiety and somatization disorders. Fortschr Neurol Psychiatr 1998, 66, S3�8. 53. Whitlock FA. The aetiology of hysteria. Acta Psychiatr Scand 1967, 43, 144�62. 54. El-Rufaie OEF, Absood GH. Validity study of the self-reporting questionnaire (SRQ-20) in primary health care in the United Arab Emirates. International Journal of Methods in Psychiatric Research 4, 45�5. Psychological morbidity in primary health care in Oman a preliminary study METHOD Subjects Assessment Somatization Psychological morbidity RESULTS Socio-demographic Features Prevalence of Somatization Prevalence of Psychological Disorders Figure 2. Performance on Self-Reporting Questionnaire Relationship Between Psychological and Somatization Indices DISCUSSION CONCLUSION ACKNOWLEDGEMENTS REFERENCES