Lipkowski [3] defines somatization as "a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them." He added that this tendency is usually assumed to be a response to psychosocial stress. Lipkowski's formulation has four components: experiential (the patient's experience of distress), cognitive (the patient's attribution of the distress to physical illness), observational (the physician's negative findings), and behavioral (the patient's decision to seek care). McDaniel and colleagues [4] observe that persistent somatization (somatic fixation) can occur either with or without organic disease. They define somatic fixation as "a process whereby a physician and/or a patient or family focuses exclusively and inappropriately on the somatic aspects of a complex problem." McDaniel and colleagues' formulation thus recognizes the roles of the physician and patients' families in the process. Somatization was originally related to the psychoanalytical concept of conversion: that is, the transduction of a psychological conflict into bodily symptoms. Conversion was viewed as a defense mechanism through which patients avoided dealing with the conflict and gained some relief from threatening circumstances (secondary gain). Classic psychosomatic theory distinguished between the direct physiologic effects of emotion and conversion effects, in which psychological conflict could be translated into bodily symptoms by symbolic processes. Symptoms of conversion were, therefore, considered to be forms of communication rather than physiologic disturbances [5]. Lipkowski's definition is independent of psychoanalytic concepts.

Somatization has now replaced the older terms hysteria and neurasthenia. Kirmayer and Robbins [6] state that in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) [7], "the classic concept of hysteria was split to form a number of ‘somatoform’ disorders." Conversion disorder (Hysterical disorder, conversion type) was retained as a physical expression of psychological conflict or need that is not under the voluntary control of the patient. Evidence of the psychological origins of the symptom includes secondary gain and a temporal association between an environmental stimulus and the origin of the symptoms. In this section of the DSM-III, conversion disorder alone provided a theory to account for symptoms. Somatization disorder was defined by the patient's age at onset (before 30 years), chronicity, number of symptoms, and absence of organic pathology. Psychogenic pain disorder was defined as pain without, or out of proportion to, organic pathology; evidence of secondary gain or an environmental stimulus should be present. Hypochondriasis retained its classic definition of "an unrealistic fear or belief of having a disease ... despite medical reassurance. ... ." Atypical somatoform disorder was a residual category, for use when physical symptoms are not explained by organic findings or known pathophysiologic mechanisms and are "apparently linked to psychological factors."

In the fourth edition of the DSM [8], atypical somatoform disorder is replaced by "undifferentiated somatoform disorder" and is defined as one or more physical complaints lasting more than 6 months and causing significant distress; symptoms that either cannot be explained by a known general medical condition or drug or are in excess of what would be expected from physical findings; and a disorder that is not feigned and is not accounted for by another mental disorder. Although evidence of psychological problems is not among the diagnostic criteria, the description of the condition [8] states that

"medically unexplained symptoms and worry about physical illness may constitute culturally shaped ‘idioms of distress’ that are employed to express concerns about a broad range of personal and social problems, without necessarily indicating psychopathology."

Neurasthenia, characterized by fatigue and weakness, is included in this category. Somatoform disorder not otherwise specified is a somatoform disorder that has been present for less than 6 months.

Given the looseness of these definitions, it is a short step to diagnosing any patients with unexplained symptoms as having a somatoform disorder. Moreover, to say that symptoms are "employed to express concerns" [8] implies an intention on the part of the patient. After considering the difficulties with the categorization of these disorders, Kirmayer and Robbins [6] suggest that "with the possible exception of somatization disorder per se, the somatoform disorders appear to be best thought of as symptoms or patterns of reaction rather than discrete disorders with a discrete natural history."

The Vocabulary of Somatization

The verb to somatize and the noun somatizer are unusual in the vocabulary of medicine because they imply that patients are performing a deleterious action on their own bodies. For most diseases, no word exists that signifies the actual patient: We say that patients have pneumonia or cancer. The ending "-ic" for nouns designating patients (diabetic, schizophrenic) implies that the disease is inseparable from the person; these terms, however, do not suggest that patients are responsible for their diseases. Only the stigmatizing term somatizer implies that patients are the authors of their own bodily suffering.

Somatization is a product of western medicine's dualistic ontology. The assumption is that emotions, instead of being expressed symbolically in words, are transduced to bodily events. A further assumption is that our emotions are not embodied in the first place. Our ethnocentricity hides from us how unusual this belief is. In many societies, the concept of somatization is meaningless because distinctions are not drawn between mental and physical illness [9]. In Ayurvedic and traditional Chinese medicine, illness (the experience of symptoms) and disease (biological processes) are not separate categories. Illnesses are thought of as imbalances and are rooted in the report of symptoms. Therefore, the idea of somatization has no logical place in these systems. Even in the European tradition, the experience of illness in all forms was accorded substantial validity until the 19th century, when the emergence of modern diagnostic technology focused attention almost exclusively on bodily processes.

Bodily forms of communication are accepted in all cultures, although in western countries, verbal expression of feeling is usually considered more desirable, especially among the educated. Even the most articulate patients, however, may find it difficult to put their feelings into words. William Styron [10] described his severe depression as "so mysteriously painful and elusive in the way it becomes known to the self-to the mediating intellect-as to verge close to being beyond description." If this is so of the highly literate, how much more difficult must it be for the inarticulate? Words may also fail because the emotion is too overwhelming or because the trauma that gave rise to it was preverbal [11].

The Emotions Are Embodied

The notion of the disembodiment of the emotions is quite recent, even in western medical thought. Classical and neoclassical medical theory recognized a definite association between emotions and physical states [12]. Contrary to modern assumptions, Descartes did not deny mind-body interactions but maintained that most aspects of affective states are primarily somatic [13]. Until the 19th century, a unitary view of illness prevailed, and diagnosis often meant diagnosis of a patient rather than of a disease. The replacement of this unitary view by the notion of diseases having a bodily location led eventually to the conceptual separation of mind from body. Commenting on the manuals of clinical method that appeared at the turn of the 20th century, Crookshank [14] noted that they "give excellent schemes for the physical examination of the patient, whilst strangely ignoring, almost completely, the psychical [sic]." By that time, an enquiry into the emotions was no longer deemed necessary for the clinician's understanding of illness.

This change in the medical world view was reflected in a transformation in the popular view of the human body. For the 18th-century patient, there was no separation between the emotions and the body. Nor was there a distinct boundary between the physician's diagnostic vocabulary and the feelings of the patient [15]. To an 18th-century patient, the idea of the emotions being "in the head" would probably not have occurred.

Even as these concepts were becoming entrenched in modern medical thought, some dissenting voices were raised. William James [16] held that bodily sensations were prior to, and the origin of, emotions. Although James's theory could not account for the neurophysiologic complexities of emotional response, his central insight into the body's involvement is still valid. With the somatic marker hypothesis, Damasio [17] postulates a neural mechanism through which bodily feelings influence human response, either consciously or beneath the level of awareness; Ciompi [18] calls this process "affect logic."

Symptom attribution, a key element in the concept of somatization, is an interpretive process that is strongly influenced by cultural factors [19]. Cultures vary widely in their openness in expressing emotion and in assumptions about mind-body relations. In the West, the assumption that bodily expressions of emotions are "in the mind" (and are, therefore, not real) and the blame attached to mental illness encourage the interpretation of bodily expression of emotion as physical disease. Some psychiatrists consider blame avoidance to be the key feature of somatization [2].

The language used to discuss somatization suggests (although this is not explicit in the concept of somatization) that the expression of emotion in bodily symptoms is abnormal; that cure requires that the mental causes of the symptoms be acknowledged, verbalized, and resolved; and that symptomatic treatment is not appropriate, even though it has some empirical justification [20]. The requirement that the physician convince the patient of the mental origins of his or her symptoms may create grounds for an irreconcilable conflict: Why should patients acknowledge something that they do not feel? A diagnosis of somatization, especially when associated with the idea of primary and secondary gain, carries with it the implication of moral failure, with all its subsequent stigmatization and breakdown of relationships [21].

Another pitfall is the opportunity for the misdiagnosis of organic disease. The definition of somatization is broad enough for the clinician to diagnose as somatoform any illness that has physical symptoms but no pathologic findings as revealed by existing investigative technologies. The chronic fatigue syndrome and the irritable bowel syndrome have both been categorized as somatoform disorders, although the evidence indicates that these disorders cannot be so readily explained [22, 23]. Even patients with early multiple sclerosis have received a diagnosis of somatoform disorders.

Abandoning the Assumptions

Although the problematic nature of somatization has been widely recognized, the logical step of abandoning the concept has not yet been taken. Doing this would require us to change deep-seated assumptions. First, we need to accept that emotions are normally experienced in the body. We should reject the idea of somatoform disorders as diagnostic entities and learn that a symptom may be an embodied emotion; indeed, all symptoms, whatever their origin, have some affective coloring. Whether they are experienced as emotions may or may not be abnormal, depending on the patient's cultural background. If they are not experienced in this way, simply telling patients that their symptoms are emotional in origin will not be helpful. The connection between emotions and bodily state must be made at both the affective and cognitive levels by the patients themselves. Second, we would also have to abandon the belief that the only way to deal with embodied emotions is to retransduce them to mental states. Physical therapies may also be effective in helping patients to make the breakthrough to a new level of understanding without the requirement of verbalization. Third, with the possible exception of somatization disorder-the only category with empirical validity-somatoform disorders should not appear in textbooks of medicine and psychiatry as disease categories; this implies that they have the same epistemologic status as discrete disorders with a verifiable natural history. A likely consequence of changing our assumptions would be a need to find a new name for these illnesses, one that integrates their physical and psychological aspects.

Many of these problems would be avoided if physicians and patients became less concerned with cause and more concerned with care [22]. Once remediable causes have been ruled out, many illnesses must be managed without knowledge of their cause. Even when no specific remedy is available, wise physicians have always tried to help patients by paying attention to the particulars of the illness, diet, rest, sleep, appropriate exercise, treatment of symptoms, and emotional support. The support of the physician is crucial and is what patients regarded as "somatizers" often lack. Building trust is especially difficult when patients have experienced rejection from physicians.

When the focus is on care, attention is switched from the causes of the illness to the causes of chronicity, exacerbation, and relapse. These causes may differ from one patient to another. On many occasions, the physician will have good reason to think that the bodily symptoms are an expression of emotion that has not yet entered consciousness. Sometimes the awareness of the link is so close to conscious recognition that exploration of patients' feelings will enable them to make the connection. In other patients, reaching this level of self-understanding will be a longer process. Focusing on care does not mean abandoning the idea of secondary gain or forgetting that patients can, by responding to illness maladaptively, inhibit its resolution. Secondary gain, however, can accrue from any illness and should not be tied particularly to the so-called somatoform disorders. Trying to modify maladaptive responses carries the risk for physician-patient conflict, but this risk will be lessened if the physician genuinely recognizes a patient's suffering.

Patients vary widely in their responses to symptoms, but this need not imply that the symptoms are "somatized." Those who go to physicians regularly are likely to be more anxious than those who cope with their symptoms in other ways [23]. This explains their illness behavior, not the mechanism of their symptoms. At one extreme of the scale of responsiveness to symptoms are patients who are highly sensitive to bodily sensations and are especially likely to attribute them to bodily diseases. This classic description of hypochondria is well known and can be retained without assuming that the symptoms arise from the transduction of emotions.

Changing the language we use will not make these illnesses go away. Nevertheless, language both expresses and influences how we think and act. Although changing the words will not necessarily change our practice, we must work toward a congruence of thought, language, and actions. What changes in thought and action are required? Most important, we must recognize that the patient's experience of illness is primary. Our own system of diagnostic abstractions, although very powerful, is secondary. In the patient's experience, there may be no separation into mental and physical; illness is "a disturbance in a person's ability to relate to and function in the world" [24], whether or not it is associated with identifiable organic pathology. The biopsychosocial model [25] and the patient-centered clinical method [26] require that the clinician attend to the emotions as a routine part of the clinical inquiry. To attend to the emotions only in certain kinds of illness, or only after diagnostic testing is negative, perpetuates the prevailing dualistic distinction between mental and physical illness. All significant illness is a disturbance at many levels, from the molecular to the personal and social. This implies that some of the skills that are at present considered psychiatric will need to be developed more generally in all clinicians, especially those working in primary care, where so much general, undifferentiated illness is seen.

Dr. Epstein: Highland Hospital Primary Care Institute, and Departments of Family Medicine and Psychiatry, University of Rochester, Rochester, NY 14620.

Dr. Freeman: Byron Family Medical Centre, 1228 Commissioners Rd. West, London, Ontario N6K 1C7, Canada.