Somatoform Disorders In Crosscultural Perspective

Rather than a biological problem, the specific focal symptoms of somatization represent a cultural idiom for communicating distress and conflict (Kirmayer et al., 1998). Somatization reflects psychosocial and psychodynamic problems and stress communicated through the symptoms, which provide a cultural medium for communicating distress and social conflicts. For instance, Chaplin (1997) discusses the symptom presentation of a Chinese woman who complained about sleeplessness for excessive fire in her liver and a weakness of her heart. Chaplin notes that her actual symptoms suggested depression but that she did not understand her situation as involving depression. He suggested that these symptom presentations reflected a cultural system of expressing bodily sensations through reference to the organ systems, which are understood as metaphors for emotions. These physical terms are more socially acceptable than the expression of anger or aggression. The people, however, understand reference to a weak heart as a reference to a poor mood and the reference to fire in the liver as indicating anger or irritation.

Castillo (1997a) argues that cross-cultural assessments of the cases illustrate the inappropri-ateness of the DSM category of somatoform disorders. In China and India, psychiatrists take cases that could be classified as somatoform disorders and instead diagnose them as different forms of mental illness, neurasthenia, or hysteria. These somatoform disorders are referred to with terms used in earlier periods of psychiatry (hysteria, neurasthenia) but now subsumed within the category of somatoform disorders. The concept of hysteria originated in Western psychiatry but is no longer recognized in the DSM. Neurasthenia, referring to "tired nerves," also originated in the United States but is not currently in the DSM; it has remained a common diagnosis in China because it fits well with cultural forms of expression (Castillo, 1997a).

Because the Chinese give little attention to depressive symptoms, patients are more likely to emphasize somatic symptoms, leading to a clinical diagnosis of neurasthenia, involving somatic complaints, fatigue, and anxiety (Kleinman, 1980). The Chinese cultural emphasis on physical symptoms as a means of expressing emotional distress somatization is extremely common due in part to a lack of words for describing psychological states. This leads to their expression in terms of organs whose referents and functions are thought to affect psychological conditions. Chinese culture inhibits introspection and open expression of emotion, shaping the presentation of psychosocial stress as somatic complaints, without mention of emotional problems, distress, or depression. Physical symptoms are understood as metaphors through which emotional states and psychological problems are expressed. For instance, complaints about physical conditions such as liver disease are understood as an emotional message; rather than actual liver problems, they were really communications about anger. Nonetheless, the liver may be treated with herbs to harmonize it with other bodily functions and eliminate anger.

The association of symbolic and somatic conditions, however, conflicts with the notion of discrete disorders implied by DSM categories. Hence, somatic disorders remain as a category that places the symptoms into a diagnostic system but lacks conceptual rigor because the standard categories fail to capture the culturally significant features (Castillo, 1997a). The concept of somatization is employed in diverse ways with a multitude of meanings (Kirmayer et al., 1998). The somatoform category implies a mind-body dualism or separation not found in most cultures and a separation of mind, body, and emotion in ways inconsistent with the actual occurrence of suffering. Consequently, the diagnostic category provides little usefulness in clarifying individual conditions.