Somatization, Hysteria, or Incompletely Explained Symptoms?

In this month's In Review section, all the contributors-Dr Francois Mai (1), Dr Laurence Kirmayer and colleagues (2), and I-wrestle with the seemingly intractable and endlessly interesting topic of body-mind relations. In the first review article, Dr Mai lays out the justification for a diagnostic category of somatization disorder. He recognizes that the standard monistic approach that accepts the unity of mind and body can easily be misunderstood. In particular, while we may agree that the phenomenology of a complaint such as the experience of pain cannot be split into organic and psychological components, we must nevertheless determine whenever possible how much a patient's complaint derives from identifiable or probable physical causes and how much it derives from, or is influenced by, psychosocial factors. To assess diagnosis, causes, and treatments, both types of etiologic formulation have to be qualified and also quantified, if only very broadly. As Dr Mai indicates, the notion of somatizing or somatization has a peculiar origin in the free translation of a highly questionable concept, organsprache, which we may understand as speaking or symbolizing a problem through some constituent of the body. This speculative idea deserves extra-severe questioning on its own. In the notion of somatizing, a dubious popular psychiatric thought has been blended with the practice that psychiatrists have introduced of defining a condition in terms of hard data. The tight criteria for somatization disorder were originally introduced to circumscribe a particular group of patients who could be isolated for prognostic purposes and other research (3). Although these criteria deliberately did not include all the items that had been labelled as hysteria, the original intent was soon subverted. Guze changed the label to Briquet's syndrome (4), perhaps hoping to promote its acceptance by associating it with the extensive empirical case material of Pierre Briquet (5), but the DSM-III took over the category and labelled it somatization disorder. So far so good, perhaps, although neither Briquet's syndrome nor somatization disorder quite describe what Briquet reported (6). The DSM-III maintains the understanding that somatization disorder is somehow linked with other labels related to the psychological causation of somatic symptoms. These include conversion disorder, psychogenic pain disorder, hypochondriasis, and atypical somatoform disorder, grouped under a general heading of Somatoform Disorders, which were matched with another group of conditions identified as Dissociative Disorders. Notwithstanding a serious effort in the DSM-III to treat these conditions empirically as part of an atheoretical system, several of them quickly reverted to type in medical practice, where they were seen as based on repression and emotional conflict. The criteria for somatization disorder were changed substantially in the DSM-IV. The group was also sufficiently unstable that the term psychogenic pain disorder as such was ultimately abandoned and replaced with the term pain disorder. Current evidence suggests that pain disorder is a category that should rarely, if ever, be used (7). Meanwhile, it has also been argued that the term somatizing has multiple uses and meanings that minimize its value (8). Never mind all that. Forget the theory, as the DSM-III really tried to do, and focus on the phenomena. With regard to this approach, Dr Mai has carefully outlined the criteria and uses of a category that by now corresponds to much of what psychiatrists also call medically unexplained symptoms and that has been further explored by Dr Kirmayer and colleagues (2). Many practitioners tend to diagnose somatization disorder, and likewise pain disorder, without applying the serious restrictions that are supposed to be observed. Mai, of course, does not permit such a solecism, and after refining his patient group according to the DSM-IV diagnostic criteria, which are essentially those of the ICD-10 as well, he is left with a group for whom he recommends cognitive-behavioural therapy (CBT) (1). …

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