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SOMATIC PRESENTATIONS: CULTURE |
From the Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec, Canada.
Address correspondence and reprint requests to Laurence J. Kirmayer, Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry, Sir Mortimer B. Davis-Jewish General Hospital, 4333 Cote Ste Catherine Rd., Montreal, Quebec H3T 1E4, Canada. E-mail: laurence.kirmayer{at}mcgill.ca
ABSTRACT
Objectives: To review the relevance of cultural models in the generation and amplification of somatic symptoms and syndromes.
Methods: Based on a selective review of literature, we examine evidence that cultural and personal explanatory models can contribute to the pathogenesis, symptomatology, and chronicity of medically unexplained symptoms and functional somatic syndromes.
Results: In the contemporary world, culture involves flows of information, roles, and institutions that offer individuals multiple models for understanding illness. Cultural models include 1) explanatory models, which make causal attributions and impute specific mechanisms or processes of pathophysiology; 2) prototypes, which are salient images or exemplars drawn from personal experience, family, friends, mass media, and popular culture that are used to reason analogically about one’s own condition; and 3) implicit models and procedural knowledge that may be difficult to articulate because they are embedded in body practices and ways of experiencing distress. Symptom attributions and explanations can participate in vicious circles of symptom amplification that give rise to culture-specific varieties of panic disorder, hypochondriacal worry, and medically unexplained symptoms.
Conclusions: Clinical research using the methods of experimental cognitive and social psychology as well as community-based ethnographic and ecological research are needed to advance our understanding of the impact of personal and cultural models on somatic distress. Nevertheless, the current state of knowledge on social and cultural dimensions of somatic syndromes suggests a typology of forms of psychosomatic and sociosomatic looping that has implications for the nosology of somatoform disorders.
Key Words: medically unexplained (somatic) symptoms • explanatory models • symptom attributions • somatoform disorders • culture • diagnostic nosology
INTRODUCTION
The somatoform disorders bring together three conceptually distinct sets of clinical problems: 1) patients with excessive bodily preoccupation, illness worry, or the unwarranted conviction that they are ill; 2) patients with medically unexplained symptoms or functional somatic syndromes (e.g., fibromyalgia, irritable syndrome, chronic fatigue, nonulcer dyspepsia, and various chronic idiopathic pain syndromes) that are presumed to be due to psychological factors; and 3) patients who present clinically with somatic symptoms or concerns but who can be diagnosed with another psychiatric or psychological disorders (e.g., major depressive disorder or panic disorder) that accounts for their bodily symptoms (1). Although these problems often co-occur and each can lead to the other, they can also occur in isolation suggesting that distinct mechanisms are involved. There is evidence that cultural ways of understanding the body, interpreting symptoms, and expressing distress can shape each of these problems (2,3). In this paper, we explore some implications of work on cultural models for rethinking the nature of somatoform disorders and for research that can inform future revisions of diagnostic systems.
Culture in a Globalizing World
Any discussion of cultural models must begin with a consideration of what the term "culture" means in the contemporary world. Although in much psychological and sociological work on illness behavior, culture has been conflated with ethnicity, race, or geographic origins in the contemporary world, every society, geographic region, and ethnic group participates in multiple coexisting, intertwined cultural systems. Current anthropological views emphasize that cultures are fluid, heterogeneous, hybrid systems of knowledge, institutions, discourse, and practices that vary over time and location (4,5).
Contemporary views of culture recognize the dynamic interplay between individuals’ agency and social processes of discursive and institutional power, often expressed through the control of technical knowledge and professional authority (6–8). Cultures function as both resources for and constraints on individuals’ constructions and construals of experience.
Research that compares ethnic or cultural groups in terms of group means is ill suited to capture this process of cultural shaping of illness experience. The majority of epidemiological studies that report on ethnoracial blocs in the United States (e.g., African-American, Hispanic, Asian American) or some other crudely defined ethnic group cannot shed much light on the impact of culture on psychopathological processes. Specifying ethnicity more precisely does not get at the real issue, which is the heterogeneity within even well-defined ethnic groups. More proximal measures of the impact of culture on symptom reporting and illness behavior are needed. For research to advance on cultural variations in psychopathology, we need to go beyond conventional group labels to examine the specific biological, psychological, or social mediators of cultural difference. For example, if cultures differ in the categories and concepts they provide to interpret and explain physical symptoms, we need to examine individuals’ use of these attributions directly rather than simply using ethnocultural identity as a proxy for the specific cultural factors that underlie the attribution. This is a crucial shift in paradigm from group comparisons based on ethnic identity toward careful measurement of potential mediators of cultural influences on behavior, which include bodily processes, cognitive models, modes of expression and narration of distress, social interactions, and institutional practices. It requires using measures that have been validated across cultures but has the potential to yield much more consistent and useful results, not only to guide cross-cultural applications of nosology, but also to advance the basic science of psychiatry and psychosomatic medicine.
Cultural knowledge about illness is encoded, maintained, and transmitted in a variety of different ways with corresponding differences in how it can be accessed and how it may influence psychopathology. Some knowledge is encoded in cognitive schemas of various types that may include explicit models of physiological process or mechanisms, networks of associations, or systems of propositions that constitute diagnostic criteria and ways of deducing the consequences of events (e.g., "if you have a stuffy nose, you may have a cold"). This is the sort of knowledge that contributes to explanatory models from which one reasons "logically." Such reasoning is not usually via strict syllogism but follows a variety of judgment heuristics using "bounded rationality"—rules of thumb for estimating the consequences of actions that have built into them various cognitive and affective biases (9). The explanatory model perspective in medical anthropology, developed by Arthur Kleinman and associates, has established the importance of causal attributions and more elaborate ethnophysiological theories in illness experience, symptom-reporting, help-seeking behavior, and treatment response (10–13).
Cultural knowledge about illness is also conveyed in salient prototypes or exemplars: images and stories of others’ experience or of one’s own past experiences that are used to reason analogically about one’s current situation (14). These prototypes may be salient because they are personally meaningful and emotionally vivid, they are given social authority through the status of the exemplars, or they are consonant with other cultural values or institutions.
The explanatory model perspective in medical anthropology assumes that cultural knowledge is largely explicit and can be accessed by asking individuals what they think. However, knowledge is also encoded in various implicit ways; e.g., patterns of association that are acquired outside of conscious awareness and that result in dispositions to respond to events in particular ways. This implicit knowledge can be measured by observing individuals’ behavior or by analyzing illness narratives for their underlying structure (15,16).
Cultural knowledge is also socially embodied, residing in social institutions and their associated rules, roles, and practices. These social institutions and practices may be expressed through explicit directives, discourse, and technologies or contribute to tacit background knowledge (17). Social background knowledge may be hard for individuals to become aware of and articulate both because it is taken-for-granted and because it is distributed, that is, not held by any single individual but parceled out among many actors and emergent from their cooperative interaction.
In addition to the impact of culture on basic psychophysiological processes, it is important to recognize that classifications of mental disorders, diagnoses, and related professional practices also are part of cultural systems. Hence, to create useful diagnostic systems and guidelines for practice, we need to consider the impact of local and international professional agendas and health care systems and the ways in which professional models are appropriated by pharmaceutical marketing, promoted through mass media, and turned into popular models that individuals use to understand their illness.
Impact of Explanatory Models on Symptom Reporting
The semiotics of biomedicine assumes that complaints about bodily function are more or less direct indices of impairments of organ tissue or function, neglecting the fact that these complaints emerge from processes of attention, interpretation, labeling, and social presentation (18). The translation or transduction of a bodily process into a salient experience and a verbal report is mediated by perceptual, cognitive, interpersonal, and social processes. A minimal set of these mediators would include attentional strategies (e.g., focused attention, distraction, or dissociation); symptom and illness attributions or interpretations in terms of cognitive models or schemas; processes of organizing experience in terms of narratives that locate distress in temporal accounts of causes, consequences, and implications for health and identity; and processes that include culturally shaped ways of understanding and communicating one’s experience and the response of others within family, work, health care, and other social contexts (2,19,20). This cognitive and social shaping of somatic distress is crucial for understanding the exaggerated bodily concern and somatic complaints that characterize the somatoform disorders.
Ordinary fluctuations in somatic regulatory systems as well as states of strong emotion or stressful life events give rise to transient experiences of bodily distress that can be interpreted as symptoms of illness. To become chronic and disabling, however, additional processes must come into play to create vicious circles of symptom amplification. These positive feedback loops are mediated by the meanings ascribed to symptoms.
Acute symptoms and distress prompt a search for meaning (21). Every culture provides explanations and causal attributions for somatic symptoms (22). These explanations, in turn, set up expectations that influence the ways that individuals attend to their bodies and the sorts of symptoms they recognize and report to others. Symptom attributions and interpretations are not static but dynamic and malleable, reorganized cognitively and renegotiated with others in ongoing processes of psychological adaptation and social positioning. The meanings inherent in cultural models may amplify distress or lead individuals to ignore or deny specific symptoms, which are threatening or stigmatizing (23).
Although the body is the vehicle for our engagement with the world, producing the basic conceptual models and metaphors we use to think with (24), the healthy body is largely absent from awareness (25). The body becomes an object of attention in itself mainly at moments of unusual pleasure, effort, or discomfort. Bodily sensations or experiences may become salient for a variety of reasons: a) unusual quality or intensity; b) functional impairment; c) contiguity or association with other salient events; and d) availability of treatment or other plans of action. Cultural models also may lead individuals to search for and identify specific symptoms and syndromes that fit salient templates.
The body produces a constant "white noise" of somatic sensations that are potential symptoms, and this background noise increases as we age (26). Physiological perturbations, emotional arousal, and social conflict can all intensify these sensations so that they cross a perceptual threshold and are perceived as disturbing. Symptom schemas assign meaning to sensations, and illness schemas organize patterns of symptoms into coherent entities according to folk knowledge (27). Such schemas may be anchored in causal explanations but they also reflect the sociomoral and cultural meanings of distress.
Explanatory models include explicit notions of cause, course, appropriate proper treatment, and likely outcome. The models may be specific to particular symptoms, syndromes, or disorders or may cut across whole categories of problem. Some like "stress" serve as all-purpose explanations (28). Explanatory models are shaped by local theories of the body (ethnophysiology), person (ethnopsychology), and the nature of health problems and adversity, which often includes social, moral, and spiritual ideas (27,29).
Qualitative health research shows that people bring multiple models to bear to explain distress and decide what to do about it (30). In a community study of people with medically unexplained symptoms, most participants were able to give multiple explanations for symptoms their doctors had not explained (31,32). These typically included stressful social circumstances that they had not brought to their doctor’s attention because they felt there was a lack of opportunity, interest, or relevance to the biomedical agenda.
In addition to explanatory models identified in medical anthropology, individuals may reason about their condition in terms of salient prototypes drawn from their own previous experience, family members, friends, mass media, and popular culture (33). Prototypes are images or models that are used to reason analogically about current illness experience. Prototypes may or may not include explicit causal attributions or ideas about mechanism but may nonetheless convey ideas about what the appropriate treatment would be for a problem and its likely outcome. A study of patients with medically unexplained symptoms identified by their primary care providers as high utilizers found that many had prototypes for their illness that were very compelling, such as the sudden death of a relative after suffering from symptoms that resembled the patients’ symptoms. This prototype was the source of persistent concern (34). Such prototypes may function as "rogue representations" (35)—persistent disturbing images and ideas that are not readily refuted or displaced by medical explanation or reassurance and that therefore contribute to persistent somatic preoccupation, concern, and help-seeking.
Knowledge about illness is also encoded in "chain complexes": schemas based on associative chains that are based on the contiguity of experiences, actions, and events. These schemas may be acquired through "Hebbian learning," in which salient sensations and events that co-occur repeatedly become associatively linked (36–38). Hebb conjectured that neurons or "cell assemblies" (small neural networks) would tend to become functionally linked if they were repeatedly activated at the same time (36). There is now evidence for this type of associative learning by contiguity in a variety of neural systems (e.g., long-term potentiation in the hippocampus) and it provides a potential mechanism for the acquisition of rudimentary sensorimotor schemas through simple exposure to sequences of sensations, actions, and events (39). A similar mechanism may operate to organize social knowledge in terms of the parallels between our own actions and experiences and our perceptions of the actions and experiences of others (including somatic sensations and emotions), as suggested by recent work on mirror neurons (40). Importantly, for our understanding of the embodiment of cultural models, these schemas may be implicit (i.e., acquired unintentionally, activated automatically, and not directly accessible to awareness). Chain complexes may link a variety of somatic sensations, actions, and expected outcomes in ways that influence illness behavior even though the person cannot give an explicit account of a cultural model.
The models that individuals use to make sense of bodily experience may vary with social context (30). Thus, the same person may think about and present their problem in one way in the physician’s office and another way at work or at home. The organization of the health care system itself may have a significant impact on the use of cultural models. The finding that, in health care systems where primary care physicians have a more personal and ongoing relationship to patients, there is a lower prevalence of somatoform diagnoses (41) points to the notion that when there is trust and open communication, it is easier to find explanations for distress—whether that involves explaining somatic symptoms in terms of distributed psychophysiology or acknowledging the social and psychological factors that contribute to making bodily symptoms intolerable (30).
Cultural Models and Symptom Experience
These considerations on the nature of cultural models are pertinent to understanding the impact of culture on somatic distress. There is evidence for cultural influences on symptom experience and reporting at multiple levels, including psychophysiology, attention, symptom attribution and interpretation, modes of coping, and help-seeking and treatment. These cultural influences are reflected in a range of phenomena relevant to psychiatric nosology, including culture-specific symptoms and syndromes as well as styles of clinical presentation.
Cultural explanations may give rise to unique symptoms and concerns like semen loss, genital shrinking, or heat in the head. The prevalence of explanatory models and prototypes may also influence the prevalence of specific clinical presentations of symptoms and syndromes. Finally, explanatory models indicate the significance and seriousness of symptoms, determining whether bodily symptoms will give rise to anxiety, help-seeking, and disability.
Specific somatic symptoms are associated with prevalent cultural explanations that have been described in terms of somatic syndromes. For example, losing semen in the urine is associated with "dhat syndrome" in India, based on the notion that semen concentrates vital energy (42,43); epigastric burning is associated with hwa-byung in Korea ("fire illness"), based on the notion of an imbalance of "fire" as a basic constituent of the body (44,45); heat in the head is a nonspecific symptom commonly reported in equatorial Africa, based on notions of the importance of central heat in the constitution of the person (46,47).
Certain symptoms may be more prevalent because they form part of an illness prototype. For example, loss of consciousness was reported more frequently in the Puerto Rican Epidemiologic Catchment Area Study than elsewhere in North America and this has been traced to the influence of the cultural template for ataque de nervios, an "attack of nerves" that may be associated with a wide range of symptoms including shouting, crying, and dissociative behaviors including apparent loss of consciousness (48–50).
Cultural models not only shape symptom reporting but also can contribute to psychopathological processes. For example, in an important body of work on panic and anxiety disorders among Southeast Asian migrants in the United States, Hinton and colleagues described a series of culture-specific vicious circles in which ethnophysiological notions interact with memories and bodily conditioning to give rise to disabling symptoms (51–57). Catastrophizing interpretations of sensations associated with orthostatic hypotension, dizziness, and other common sensations can lead to vicious circles with panic attacks or anxiety about somatic illness.
Understanding the social and psychological processes that reinforce or stabilize particular symptom and illness meanings and that make them resistant to change may lead to a useful nosology that is keyed to differential therapeutics. In addition to understanding the individual psychological dynamics of managing the meaning of distress in terms of the maintenance of self-esteem, self-efficacy, and avoiding stigma or the fearsome implications of illness and mortality, we need to consider the social consequences of construing symptoms in particular ways. Social and cultural processes may amplify and spread particular meanings and models of distress and that may modulate attention to the body and help-seeking. Cultural models, whether encoded in individuals’ cognitive schemas, in body practices, or in social roles, discourse, and institutions can have an impact on psychological processes of attention, interpretation, and coping. Through these psychological processes, cultural models can regulate symptom experience, reporting, help-seeking, adaptation, treatment response, and disability.
Locating Somatic Distress: From Psychosomatics to Sociosomatic Theory
Although the notion of culture-bound syndromes has dominated an older literature in cultural psychiatry, more recent ethnographic research makes it clear that many of the conditions labeled culture-bound syndromes were not syndromes but rather metaphorical descriptors or everyday terms, causal attributions or explanations, or cultural idioms of distress that can be used to describe a wide range of different somatic experiences of varying pathological significance (58). This is the case for many somatic "syndromes" including dhat and hwa-byung. Such culturally shaped categories and ways of describing the bodily distress can influence somatic symptom experience and illness behavior but do not, in themselves, constitute discrete syndromes or disorders.
Cultural idioms of distress are culturally prescribed modes of understanding and narrating health problems and broader personal and social concerns (59). They usually do not indicate psychopathology and may be linked to popular explanatory models or to sociosomatic theory (31). Cultural idioms may reflect more elaborate cultural models or employ evocative metaphors without a well worked out conceptual model. For example, the notion of "nerves" has been a popular idiom in many cultures going back to the late 19th century (60). The concept of "cultural idioms of distress" was introduced to draw attention to the fact that reports of bodily distress can serve a communicative function (59). Somatic distress may be a way to express dissatisfaction with living conditions, legitimate difficulties in performing social roles, and allow the individual to seek outside help through the health care system. If the social conditions that give rise to distress are implacable and persistent, then the person may present with persistent symptoms.
The social meaning of somatic symptoms includes their use as ways of talking about or alluding to other forms of distress. For example, talk of burning in the epigastrium may be an indication of reflux esophagitis or other upper gastrointestinal problem, but it is also part of the Korean understanding of hwa-byung, fire illness, in which anger, usually from interpersonal conflicts or injustices, manifests itself as a physiological imbalance with corresponding symptoms (44). This sort of link between a symptom and an ethnophysiological theory may reflect an explicit explanatory model but it can also follow from more analogical reasoning based on the natural metaphoricity of sensory and affective experiences (61,62). Hence, anger is associated with heat because of the flushing that can accompany the emotion, and sensations of burning resemble tactile sensations of heat. The connections do not require an explanatory model. The process runs the other way: bodily experiences provide analogies that give rise to metaphors which, in turn, are elaborated in explicit conceptual models and illness narratives over time (63).
Whether they reflect elaborate models or more partial and temporary metaphors, cultural idioms may create the impression that a problem is fundamentally somatic and may lead to iatrogenic somatization, when the clinician ignores the socioemotional dimensions of distress and pursue somatic explanations. When medical investigations fail to provide an explanation, physicians may view patients as somatizing when, in fact, the patients were aware of the social and emotional antecedents of their bodily distress from the start. Many patients with somatic cultural idioms of distress will acknowledge the social problems that exacerbate their symptoms if they find a sympathetic listener (30,64,65). In biomedical health care settings, however, they may downplay or deny the social dimensions of their distress either because they view it as inappropriate to discuss with a medical practitioner or because they fear stigmatization.
Diagnostic systems are also cultural artifacts. In addition to serving as a guide to differential therapeutics, diagnostic labeling provides meaning for suffering, indicates its seriousness and significance to others, and maps its social consequences. In the absence of a clear diagnosis or effective treatment, patients suffer from uncertainty and may engage in efforts to find a definite diagnosis and legitimation for their suffering. Absent, equivocal, and contested diagnoses pose special dilemmas for patients and some of what is seen as psychopathology may reflect this social predicament (66,67). Although psychological explanations for persistent symptoms are always available, framed in terms of the impact of stress and difficult life circumstances, they may be unsatisfying to patients for many reasons: a) they may seem obvious and be part of taken-for-granted conditions of social adversity; b) they can imply a degree of personal weakness; c) they are associated with other highly stigmatized psychiatric conditions; and most importantly, d) they may not to lead to significant relief (68,69).
Even when models are popular and widely shared, others may contest them. The dynamics of this conflict and contest of models have important implications for health and illness. For example, challenges to the legitimacy of a symptom or condition may put the suffering individuals in the position of having to prove the veracity, severity, and seriousness of their complaints. Chronic fatigue syndrome provides a good example of a situation where many individuals faced with disbelief and the potential for psychological stigmatization have tended to emphasize the gravity of their illness and reject any psychological dimension as a threat to the legitimacy of their suffering (70). As a result, patients with chronic fatigue syndrome are less willing to endorse psychological contributors to their condition than are patients with other conditions like rheumatoid arthritis (71).
A Typology of Looping Effects: Varieties of Somatic Amplification
A variety of factors contribute to amplifying or intensifying symptom experience and associated illness behavior through direct effects (e.g., anxiety leads to increased somatic symptoms); only when these processes feed back into or reinforce themselves in some way do they become the vicious circles that characterize looping effects. A consideration of the varieties of looping effect could lead to a nosology of somatic syndromes based on mechanisms rather than symptom counts or clusters. These loops can be characterized in terms of the pivotal processes forming the feedback loops that amplify distress (Table 1). Current evidence would suggest the following factors that may contribute to the intensity and persistence of somatic symptoms and that may become involved in feedback loops: a) physiological perturbation (as a result of functional disturbances of autonomic and other regulatory systems, affecting visceromotor, pain, and other sensorimotor systems); b) emotional distress (in the form of an affective or anxiety disorder or other forms of emotional arousal and distress that do not reach the threshold for clinical diagnosis in their own right); c) disturbances of attention (leading to increased bodily focused attention or, in contrast, ignoring sensations or dissociation); d) misattribution (linking sensations to pathological causes); e) catastrophizing or other types of pathologizing cognitions that undermine coping and elaborate negative expectations associated with symptoms; f) interpersonal responses that may reinforce specific verbal and behavioral expressions of bodily distress; g) health care, disability, and other systemic responses that investigate, diagnose, legitimate, and ratify symptoms and syndromes of bodily distress; and h) larger social and cultural models and institutions that sanction specific modes of talking about and responding to bodily illness. These processes all participate in the ordinary regulation of symptom experience; when they exceed normal parameters, all can be etiological factors in giving rise to persistent bodily preoccupation or somatic distress syndromes.
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Hypochondriacal worry may arise from loops that resemble those of panic disorder: emotional arousal (anxiety) gives rise to somatic sensations, which are interpreted as evidence of a threat to one’s health, which gives rise to more emotional arousal, and hence more intense symptoms. In the case of panic disorder, the interpretation is that something catastrophic is about to happen. In the case of hypochondriasis, the feared outcome may be less immediate and result in less intense anxiety but there is more persistent concern to collect information, focus on, and monitor one’s body, and seek reassurance from health providers (which is often perfunctory and unsatisfactory), resulting in increased conviction that something is wrong (72).
A variety of isolated bodily complaints may be driven by attentional processes that increase body focus and hence lead to more symptom reports. Attention to the body may raise awareness of one’s mortality and hence be a source of anxiety in itself (73). Attentional processes may also lead to ignoring distress and hence with delays in help-seeking or lack of adherence to treatment regimens. In the case of conversion symptoms, symptoms may arise and persist because of dissociative processes that divert attention from symptom and illness representations (35,74).
Ways of coping with symptoms may inadvertently lead to exacerbations. For example, many people with symptoms of chronic fatigue may tend to reduce their activity and engage in prolonged bed rest, thereby leading to physical deconditioning and exacerbating symptoms of fatigue, weakness, and exercise intolerance (70). Similar behaviors can exacerbate other physiological systems, resulting in symptoms such as orthostatic dizziness.
Personality and social factors interact with ways of coping (75). For example, rather than adopting a gradual and graded process of increasing their activity, some patients with chronic fatigue or pain may overexert themselves in initial efforts to push past their symptoms, giving rise to new or intensified symptoms. Social influences come into play when prevalent cultural models or the response of others suggest that such recurrent symptoms are signs of serious exacerbation or new injury and must be avoided.
The social reinforcement of a specific bodily complaint may increase bodily attention, in effect, encouraging people to look for, notice, and label the sensation, to interpret it as worrisome, and seek medical attention. Parental modeling of symptoms during childhood and current reinforcement contingencies (including verbal expressions of sympathy, release from responsibilities, and assistance given when sick) influence symptom reporting, even when life stressors and illness attitudes are statistically controlled (76,77). Interpreting and labeling sensations in terms of psychological or somatic schemas itself are shaped by reinforcement contingencies (78). In chronic pain, the response of others may reinforce pain behavior and experience. Spouses’ positive attention to their partners’ display of pain can inadvertently increase reported pain, pain behaviors, and disability (79,80). Differences in spouse response may account for difficulties in coping with chronic pain and levels of disability (81). Such responses to social reinforcement contingencies can occur without conscious awareness.
Social contingencies are also associated with specific roles and statuses. The "sick role," described by Parsons, exempts the ill individual from certain responsibilities and offers them care and concern (82). These social responses may reinforce sick behavior. Again, this can occur unintentionally and outside of conscious awareness. Professional diagnostic practices are important elements in this process of social shaping of distress. The experience with repetition strain injury in Australia illustrates this social looping effect (83–86). Finally, there are larger institutional forces, including political economic considerations such as the structure of health insurance and compensation systems, and the marketing of specific disease entities and treatments.
All of these social factors give rise to what the philosopher Ian Hacking has called an ecosocial "niche" (87). Hacking pointed out that psychiatric diagnostic categories can become part of social looping effects in which a variety of contingencies reinforce the existence and prevalence of the disorder (88). The protean forms of hysteria or mass psychogenic illness described over the years are a prime example of this social looping effect. It is possible to describe hysteria at a sufficiently abstract or general level that it transcends specific cultural and historical forms. To do this, though, hysteria must be characterized not by its symptoms, which vary with cultural models and modes of expressing distress but by some more general characteristic or index of underlying mechanism. Hacking described social looping effects in very broad terms as resulting from the existence of a social or "ecological" niche consisting of an available label, prescribed role, social institution, and economic factors that encourage patients and physician to populate this category. We need to understand this and make the links back to specific psychological processes, to identify the points at which those social factors exert their influence on the individual through the dynamics of meaning in illness experience.
CONCLUSION
Increasing knowledge of the nature of cultural models and their influence on bodily experience has implications for research on somatic distress syndromes and for efforts to rethink the nosology of somatoform disorders.
Epidemiological Research
Epidemiology and clinical diagnosis both assume an indexical relationship between symptom reports and underlying physiology and illness experience, but the relationship is embedded in and mediated by cognitive and social processes. Symptoms can exist in the absence of cultural models and can be elicited and counted by suitable questions and probes but their recognition, salience, significance, and organization into syndromes reflects cultural models rather than purely physiological processes. Epidemiological research must be designed not simply to identify some putative universal configuration of somatic distress but to tease apart the psychophysiological and sociophysiological processes that contribute to somatic distress.
Standard symptom indices do not canvas the wide range of symptoms found in diverse cultural groups, some of which may be important indicators of coexisting affective and anxiety disorders, others of which constitute significant health concerns in their own right. We can only accrue knowledge about cultural syndromes and explanations if we ask the right questions. We need to use expanded symptom inventories that canvas symptoms relevant to specific cultural contexts.
We need more research on the ways in which culture and context shape the somatic clinical presentations of the range of psychiatric disorders. We need integrated epidemiological and ethnographic research, both in the community and the clinic, to examine the relationship between cultural idioms of distress and clinical syndromes. The extensive work on ataques de nervios in Latin populations is exemplary in this regard (48,49,89–91).
We need to study the impact of introducing new labels and categories in specific social contexts. The history of repetition strain injury is a striking example of how changes in diagnostic fashion can interact with social stressors to give rise to a social looping effect that greatly increases the prevalence of a specific somatic distress syndrome (92).
Research on the Mechanisms of Somatic Distress Syndromes
Looping effects are core mechanisms of psychopathology that can be studied in their own right. However, they require methods of study that go beyond self-report measures. Recent studies using functional brain imaging hold the prospect of allowing more direct study of attentional mechanisms and other processes that underlie implicit learning. Attributional processes have been studied with explicit questions but can also be elicited in indirect ways that may yield better measures of automatic thoughts and implicit associations. Coping strategies can be studied in laboratory analogs or in daily life with behavioral diaries or experiential sampling. All of these methods go beyond self-reports, which are close to the outcome of symptom-reporting and may not capture mediating mechanisms.
Epistemology, Politics, and Pragmatics of Somatic Diagnosis
The category of somatoform disorders, based on symptom counts and the absence of medical explanation or the presumption of psychological mechanisms, has had limited utility in primary care and other medical settings where most patients with somatic concerns are seen (93). The somatoform disorders are part and parcel of a dualistic medical system that requires diagnoses for patients who fall through the cracks of biomedical diagnosis. The somatoform category serves a useful administrative and organizational function in general hospital psychiatry because the availability of these diagnostic labels ensures that everyone can get a diagnosis: idiopathic pain becomes pain disorder, unexplained symptoms become undifferentiated somatoform disorder, and so on. Psychiatric labeling of these conditions assigns clinical responsibility but does not necessarily indicate any increase in understanding or guide to effective therapeutics. Instead, the diagnosis of a somatoform disorder conveys psychiatric stigma, perplexes patients because it implies their problems are mental rather than physical, and justifies therapeutic nihilism on the part of clinicians.
The existing classification of somatoform disorders has also not served to capture the important cultural variations in modes of somatic expression of distress, which do not reflect discrete disorders bur rather the use of cultural idioms to signal concerns that are not only about bodily health but are linked to social predicaments. The existence of the whole category of somatoform disorders is largely the consequence of a dualistic ontology and epistemology that is reflected in the structure of biomedical health care. The category may introduce new problems in health care systems not founded on this dualism. Exporting the somatoform disorders across cultures, therefore, seems to be a poor idea for several reasons: 1) it exports an ontological dualism that other systems of medicine may not have; 2) it confounds the notion of a cultural idiom of distress or mode of suffering with a disorder; and 3) it ignores the specificity of somatic symptoms and syndromes, which may make more sense to people in the clinical negotiation and which can guide the clinician in a symptom-focused approach to distress.
Rethinking the Nosology of Somatoform Disorders
In current nosology, somatoform disorders are defined in largely negative terms as "medically unexplained symptoms." This label names a social predicament rather than a discrete syndrome or disorder and hence, should really be classified as a V-code in the Diagnostic and Statistical Manual of Mental Disorders. The identification of somatoform disorders as a distinctive form of psychopathology rests on the assumption that there are specific psychological processes that give rise to symptoms or amplify distress and maintain help-seeking and disability. However, the same processes of symptom perception and interpretation that influence somatic syndromes also affect help-seeking and health care utilization more generally (94). Similarly, the same social and cultural factors that shape illness experience and expression in the somatoform disorders contribute to the wide variations in coping and adaptation to other medical and somatic conditions. This suggests that it may be helpful to develop a description of various dimensions of illness cognition, behavior, and interaction under the rubric of "psychological factors affecting medical conditions" (95). Much of what is currently diagnosed as a somatoform disorder would then be described as somatic symptoms or syndromes on Axis III (i.e., a medical condition), qualified by a description on Axis I of the various psychological and social factors that may be leading to symptom amplification (or minimization and denial), poor coping, excessive health care utilization, functional impairment, and disability.
A revised nosology should make it possible to characterize these aggravating factors independently of the original causes or precipitants of somatic distress. Developing a separate scheme for psychological factors that affect medical conditions could serve the function of linking diagnosis to differential therapeutics, at the same time avoiding the negative effects of labeling such problems as discrete psychiatric disorders. Looping effects that create vicious circles of amplifying somatic preoccupation, distress, and disability could be made central to a revised nosology. A typology of looping effects could be keyed to specific interventions targeting at modifying attentional strategies, emotional arousal, reattributing symptoms, reducing catastrophizing, and improving coping with distress (96).
Finally, there is a need for a social and cultural approach to the phenomenon of somatization that goes beyond the model of diseases and disorders. If the somatoform disorders reflect "abnormal illness behavior," this is not a single construct or closely related family of constructs but a normative distinction that groups together a broad set of disparate conditions and predicaments on the basis of their contravening tacit medical or social norms for appropriate behavior when sick (97–99). Grouping these dimensions of illness behavior as a family of disorders justifies an approach to research that searches for intrinsic characteristics of patients and deflects attention from understanding how problematic behavior emerges out of interactions with clinicians and a health care system unable to respond to these common predicaments. An alternative approach based on identifying and measuring psychological and social factors, including interactional problems that modulate bodily experience, may have more utility for researchers, clinicians, and patients. This could be recognized in psychiatric nosology by creating a place for the assessment of "psychological and social factors affecting bodily condition."
We thank Suparna Choudhury and Andrew Ryder for helpful comments on earlier drafts.
NOTES
Received for publication March 20, 2007; revision received July 19, 2007.
The study was supported by Senior Investigator Award MSS 55123 (L.J.K.) from the Canadian Institutes of Health Research on "the integration of culture in psychiatric theory and practice."
This article is being co-published by Psychosomatic Medicine and the American Psychiatric Association.
DOI:10.1097/PSY.0b013e31815b002c
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