- Email: [email protected]
A Chinese perspective of somatoform disorders
Journal of Psychosomatic Research, Vol.43, No. 2, pp. 115-119, 1997
Copyright© 1997ElsevierScienceInc. All rightsreserved. 0022-3999/97 $17.00 + .00
ELSEVIER
S0022-3999(97) 00037-8
EDITORIAL A CHINESE PERSPECTIVE OF SOMATOFORM DISORDERS SING LEE This patient's illnessnarrative began with the particularitiesof his physicalsymptomsbut rapidlyramified into detailedconcreterecall of past troubles, as if the somaticmetaphorhad becomethe mnemonic device for recapturingthe past. [1] In his much-cited study of Chinese patients with neurasthenia, Arthur Kleinman referred to this frequent condition in China as a "socially and culturally shaped type of somatization" [2] (p. 148). Intended or not, this study has promoted the popular notion that Chinese (and other Asian) psychiatric patients are "somatizers" who manifest few or no emotional symptoms, and attribute their distress to physical causes. But those who subscribe to this entrenched view must grapple with at least four recent findings. First, in the community as well as clinical context, somatization disorder (as defined in DSM-III) is as rare in Taiwan, Hong Kong, and China, as in the USA [3, 4]. Second, somatization, whether it is understood as a pattern of clinical presentation, the presence of medically unexplained somatic symptoms, or somatic amplification, has been found to be ubiquitous in all cultural groups and societies. Third, the psychodynamic claim that somatic and emotional expressions of distress bear an either/or relationship to each other has not been substantiated by clinical, laboratory, and community epidemiological studies. Rather, somatic and emotional symptoms are highly intercorrelated, including in the Epidemiologic Catchment Area study data [5]. Fourth, almost the whole block of somatoform disorders in the ICD-10 and DSM-IV (namely, somatization disorder, somatoform pain disorder, somatoform autonomic dysfunction, and undifferentiated somatoform disorder) are excluded in the CCMD-2-R (Chinese Classification of Mental Disorders, Second Edition, Revised), which is the latest national system of psychiatric classification used for the 1.2 billion people in China--a Chinese DSM-IV, so to speak [4]. Uncommonly noted as they are, these findings square with the overdue recognition that Chinese people, if given the opportunity to do so, readily communicate dysphoria and relate somatic symptoms to what is at stake in their local worlds of interpersonal experience--interpersonal because the locus of Chinese culture is more between people than in the minds of individuals [1, 7]. Clinically, patients' soDepartment of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA. Address correspondence (after 9 June 1997) to: Sing Lee, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, l l / F Prince of Wales Hospital, Shatin, Hong Kong. Fax: 852 2637 7884; E-mail: [email protected]
115
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Editorial
matization is less a denial of underlying "psychological lesions" than a locally appropriate strategy of engaging physicians' concern. In developing countries such as China where practitioners have neither time nor expertise for conducting psychotherapy, patients' selectively amplifying somatic distress and silencing affectivity is a form of help-seeking behavior that may simply reflect the norms and values of the health care system--in this case, the culture of overcrowded out-patient clinics where somatization is a passport to soliciting time-saving pharmacotherapy. So, somatization among most Chinese patients is best considered a co-creative process that involves physicians as much as patients positioned in particular sectors of a socioeconomically constrained health care system [5, 7]. Arguably, as Chinese society transforms as a result of changes linked to market economy, urbanization, and industrialization, and as demoralization begins to be appropriated in a less time-constrained therapeutic culture, patients' spontaneous expression of affectivity may become more common. The recent upsurge of interest in the diagnosis of depression (yiyu zheng) and psychological counseling (xinli zixun) in a number of rapidly developing cities in China [7] attests to this dynamic relationship between political economy and what medical anthropologists term "idioms of distress"; that is, culturally legitimate modes of signifying persohal distress and predicaments [2, 4, 6]. This is not to imply, of course, that the somatic presentation of distress will simply disappear. Because of the complexity of somatization in both theory and practice, the subsidiary concept of "somatoform disorders" is only a limited and limiting way of interpreting its cross-cultural variations and clinical salience. According to the ICD-10, the main features of such conditions are the repeated presentation of physical symptoms and persistent requests for medical investigations despite negative findings and reassurances by doctors that the symptoms have no physical basis. The patient usually resists attempts to discuss the possibility of psychological causation even in the presence of precipitating psychosocial stressors [8]. Embodying a Western reductionist epistemology, somatoform disorders arise from a highly reliability-driven nosology, which generalizes the medical model of mental disorders from major neuropsychiatric diseases to virtually all forms of human suffering and behavioral deviance. The hybrid (half-Greek and half-Latin) word "somatoform" is grounded in the intellectual legacy of mind-body dualism which is pervasive in Western philosophy [4]. It is alien to non-Western ethnomedical traditions which subscribe to a functional view of health and disease [9], according to which no ontological distinctions between psychiatric and nonpsychiatric, or authentic and less authentic diseases, are made. Strictly speaking, somatization is a Western cultural construction, whereas somatoform disorders enact a most radical, if not irrational, form of the mind-body discourse [7]. Not so surprisingly, Chinese psychiatrists who devised the CCMD-2-R are far from being impressed with the concept of somatoform disorders [4]. They find it a terminological puzzlement, much like Western psychiatrists may see "affectoform disorder" to be a neologism. Professor Y. X. Xu, a psychiatric luminary from Beijing, branded it as being obscure and misleading. In his view, Chinese patients willingly reveal dysphoria and usually acknowledge psychogenesis in the context of a sound doctor-patient relationship, suggesting that their somatic distress and psychic suffering are integrated, albeit loosely stitched and context-specific [10]. Cross-
Editorial
117
cultural and anthropological studies have affirmed that somatic symptoms are situated in multiple systems of meanings, can be symbolically interpreted, and serve psychosocial functions [1, 5-7]. From the point of view of patients and their significant others, no somatic symptoms are unexplainable. In this respect, the diagnostic emphasis on somatoform disorders being "medically unexplained" may be damaging to the doctor-patient relationship, as unwary practitioners mortify patients who seek specialist validation as having a less than authentic if not fictive ("It's all in your head") illness [5]. Somatoform disorders may face further problems when they are applied to China's vast agrarian and/or illiterate populations, who do not necessarily entertain the concept of functional versus organic mental disorders [9]. As medical investigations are often unavailable in their modest treatment locales, health practitioners frequently cannot ascertain whether patients' somatic symptoms are truly "medically unexplained." Because rural people are unfamiliar with biotechnological explanatory models of disease, few of them exhibit "persistent requests for medical investigations" as Anglo-American patients who are often enthused about the latest findings in clinical trials may apparently do. And when they consult traditional healers who do not make an ontological distinction between the physical and the psychological, it is unclear how the diagnostic requirement that "reassurances by doctors that the symptoms have no physical basis" (italics added) [8] could be meaningfully applied. In his commentary of international psychiatric nosology, Xu therefore admonished that the ICD-10 has unwisely borrowed the term somatoform disorder from the DSM-III-R, and that its widespread use in China may lead to inappropriate diagnosis and treatment [10]. It is perhaps no coincidence that criticisms of the concept have also been raised by Tyrer, who noted that "the introduction of the term somatoform disorders has been an American initiative, and the ICD-10 has been, somewhat reluctantly, carried in its wake" [11]. Likewise, most Japanese psychiatrists "indicated reluctance to the partitioning of neurotic disorders into anxiety, somatoform, and dissociative disorders in DSM-III, and preferred the ICD-9 classification of neurotic disorders" [12]. Clinical syndromes characterized by a varying syncretism of somatic and emotional (for example, anger, anxiety, depression, emptiness, fear, and irritability) symptoms exist panculturally and have been variously named, for example, shenjing shuairuo (neurasthenia) in China, dhat in India, shinkeishitsu in Japan, hwa-byung in Korea, shenkui in Taiwan, brain fag in Eastern Africa, and ataques de nervios in Puerto Rico [5, 6]. After mood and anxiety disorders are excluded by hierarchical criteria, they can usually be "somatized" into the category of undifferentiated somatoform disorder [7]. However, to the extent that the human body in these societies is symbolically elaborated and somatic distress has multiple layers of meaning, the somatoform label runs the risk of rendering invisible the cultural forces in these popular indigenous syndromes that powerfully shape the local worlds in which patients' suffering is negotiated and contested. For example, a study of Chinese patients with a CCMD-2-R diagnosis of neurasthenia in Hong Kong revealed that, after mood and anxiety disorders were excluded, most of them could be "forced" to receive a diagnosis of undifferentiated somatoform disorder or somatoform pain disorder. But, by focusing exclusively on somatic symptoms and by requiring the failure to recognize psychosocial causes as a crucial clinical feature, these categories
118
Editorial
did violence to patients' variegated symptom profiles and their narration in a network of cultural conflicts which characterize everyday life in contemporary Hong Kong. Their experience-distancing nature is particularly obvious when, say, undifferentiated somatoform disorder is translated as wei fen hua qu ti zhangai, which is unidiomatic and barely intelligible to Chinese people, including mental health professionals [7, 13]. Notwithstanding the hegemony of official nosology, which looms behind clinicians' thinking and practice, somatoform disorders have been found to be difficult to apply by psychiatrists (not to speak of general practitioners) in Taiwan, Hong Kong, and China, where neurosis, neurasthenia, hypochondriasis, mild anxiety, and depressive disorders are commonly used diagnostic labels [4, 13]. In fact, somatoform disorders do not seem to be a valid diagnostic category for the majority of Western patients who fall short of the criteria for mood and anxiety disorders in primary care. Based on data from the DSM-IV field trial for mixed anxiety-depressive disorder in the USA, the proposal has therefore been made that this category be reconsidered for inclusion in future versions of the DSM system [14]. Its symptom configuration, namely, a core symptom of nonspecific dysphoria and a varying mixture of somatic and cognitive symptoms, closely resembles the CCM49-2-R definition of neurasthenia in China [13]. This timely proposal attests to a genuine need for a flexibly construed somatoaffective category in both Western and non-Western nosological systems. By reuniting mind and body in clinical theory and practice, this category also encourages a useful critique of certain abiding assumptions of the DSM-IV and ICD-10 systems, such as the cultural validity of diagnostic constructs and syndromic architectures derived from an adamant adherence to the mind-body dichotomy [4]. This is not to say that somatoform disorders are no more than an imaginary disease category. But evidence is unconvincing that, after mood and anxiety disorders are systematically excluded, they constitute the next most prominent form of psychiatric disorder in any society. Future revisions of the DSM-IV or ICD-10 may retain them as a residual category, but only after somatoaffective syndromes (which may be subcategorized according to the local context) are excluded. Far more important than diagnostic controversies, effective modes of intervention for the enormous number of people who suffer from somatoaffective syndromes across all cultural groups and societies must be promptly identified. As more psychiatric treatment is predictably incorporated into primary care and as medical service becomes increasingly insurance-driven, it is necessary to explore novel and cost-effective treatment methods, such as short-term group therapy [15]. Because patients with somatoaffective syndromes do seem to benefit from "alternative" therapies, there is an urgent need to evaluate, by combining biomedical and social science methodologies, the efficacy of such methods of treatment as homeopathy, Ayurveda, and traditional Chinese medicine [16-18]. These approaches to healing do not marginalize "unexplained" somatic symptoms; integrate somatic, social, and moral therapies,, and manipulate placebo effects to patients' satisfaction [9]. They may also be integrated with allopathic methods of treatment. In China, for example, herbal tablets are sometimes prescribed along with tricyclic antidepressants for patients with depression and/or neurasthenia, partly for modulating the latter's therapeutic and side effects. The efficacy of such "holistic" methods of treatment such as
Editorial
119
acupuncture and qigong (a trance-based form of Chinese healing exercise) in the management of chronic pain and insomnia similarly warrants more empirical investigation [17]. Inasmuch as somatic symptoms may also represent a sociomoral medium for protest against inequities and a strategy for social repositioning [1, 5], an effective paradigm of care must ultimately restructure state policies and encompass socially meaningful forms of empowerment for the disenfranchised members of society. This may mean, for example, more nurseries and public housing for lower social class couples in Hong Kong, more education for women in rural China [7], and more jobs for people in societies with high rates of unemployment. In an era when health care is dictated by economic concerns, to do this is to devise ways of convincing physicians, policymakers, and politicians that health care is not just a human right, but also a way of increasing human capital [19].
REFERENCES 1. Kleinman A, Kleinman J. Remembering the cultural revolution: alienating pains and the pain of alienation/transformation. In: Lin TY, Tseng WS, Yeh EK, eds. Chinese societies and mental health. Hong Kong: Oxford University Press 1995:148. 2. Kleinman A. Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry 1982;6:117-190. 3. Hwu HG, Comptom WM. Comparison of major epidemiological surveys using the diagnostic interview schedule. Int Rev Psychiatry 1994;6:309-327. 4. Lee S. Cultures in psychiatric nosology: the CCMD-2-R and international classification of mental disorders. Cult Med Psychiatry 1996;20:421--472. 5. Kirmayer LJ, Young A. Culture and somatization: clinical, epidemiological and ethnographic perspectives. Psychosom Med (in press). 6. Kleinman A. How is culture important for the DSM-IV? In: Mezzich JE, Kleinman A, Fabrega H, Parron DL, eds. Culture & psychiatric diagnosis--a DSM-IV perspective. Washington, DC: American Psychiatric Press 1996:15-25. 7. Lee S. Estranged bodies, simulated harmony, and misplaced cultures: neurasthenia in contemporary Chinese society. Psychosom Med (in press). 8. World Health Organization. The ICD-10 classification of mental and behaviour disorders---clinical descriptions and diagnostic guidelines. Geneva: WHO 1992:161. 9. Fabrega H Jr. The concept of somatization as a cultural and historical product of Western medicine. Psychosom Med 1990;52:6534572. 10. Xu YX. About ICD-10. J Clin Psychol Med 1994;4:224-226 (in Chinese). 11. Tyrer P. Classification of neurosis. Chichester, UK: Wiley 1989:92. 12. Yamashita I, Koyama T. Neurotic spectrum disorders in Japan. In: Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric diagnosis: a world perspective. New York: Springer, 1994:97. 13. Lee S. The vicissitudes of neurasthenia in Chinese societies: where will it go from the ICD-10? TPRR 1994;31:153-172. 14. Zinbarg RE, Barlow DH, Liebowitz M, Street L, Broadhead E, Katon W, Roy-Byrne P, Lepine JP, Teherani M, Richards J, Brantley PJ, Kraemer H. The DSM-IV field trial for mixed anxiety-depression. Am J Psychiatry 1994;151:1153-1162. 15. Kashner TM, Rost K, Cohen B, Anderson M, Smith GR Jr. Enhancing the health of somatization disorder patients. Psychosomatics 1995;36:462-470. 16. Zhou K, Shu F, Chen JX, Xu SH, Zhou CF, Xu PJ, Shi L, Sang NJ. A controlled study of combination treatment of neurasthenia classified by traditional Chinese medical criteria. Chin J Neurol Psychiat 1986;19:306-308 (in Chinese). 17. McNamara S, Song XK. Traditional Chinese medicine. London: Hamish Hamilton 1995. 18. Li QF, Liu DZ, eds. Psychiatry in traditional Chinese medicine. Tienjin: Tienjin Publishing House of Science and Technology 1989 (in Chinese). 19. Desjarlais R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford: Oxford University Press 1995.
Copyright© 1997ElsevierScienceInc. All rightsreserved. 0022-3999/97 $17.00 + .00
ELSEVIER
S0022-3999(97) 00037-8
EDITORIAL A CHINESE PERSPECTIVE OF SOMATOFORM DISORDERS SING LEE This patient's illnessnarrative began with the particularitiesof his physicalsymptomsbut rapidlyramified into detailedconcreterecall of past troubles, as if the somaticmetaphorhad becomethe mnemonic device for recapturingthe past. [1] In his much-cited study of Chinese patients with neurasthenia, Arthur Kleinman referred to this frequent condition in China as a "socially and culturally shaped type of somatization" [2] (p. 148). Intended or not, this study has promoted the popular notion that Chinese (and other Asian) psychiatric patients are "somatizers" who manifest few or no emotional symptoms, and attribute their distress to physical causes. But those who subscribe to this entrenched view must grapple with at least four recent findings. First, in the community as well as clinical context, somatization disorder (as defined in DSM-III) is as rare in Taiwan, Hong Kong, and China, as in the USA [3, 4]. Second, somatization, whether it is understood as a pattern of clinical presentation, the presence of medically unexplained somatic symptoms, or somatic amplification, has been found to be ubiquitous in all cultural groups and societies. Third, the psychodynamic claim that somatic and emotional expressions of distress bear an either/or relationship to each other has not been substantiated by clinical, laboratory, and community epidemiological studies. Rather, somatic and emotional symptoms are highly intercorrelated, including in the Epidemiologic Catchment Area study data [5]. Fourth, almost the whole block of somatoform disorders in the ICD-10 and DSM-IV (namely, somatization disorder, somatoform pain disorder, somatoform autonomic dysfunction, and undifferentiated somatoform disorder) are excluded in the CCMD-2-R (Chinese Classification of Mental Disorders, Second Edition, Revised), which is the latest national system of psychiatric classification used for the 1.2 billion people in China--a Chinese DSM-IV, so to speak [4]. Uncommonly noted as they are, these findings square with the overdue recognition that Chinese people, if given the opportunity to do so, readily communicate dysphoria and relate somatic symptoms to what is at stake in their local worlds of interpersonal experience--interpersonal because the locus of Chinese culture is more between people than in the minds of individuals [1, 7]. Clinically, patients' soDepartment of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA. Address correspondence (after 9 June 1997) to: Sing Lee, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, l l / F Prince of Wales Hospital, Shatin, Hong Kong. Fax: 852 2637 7884; E-mail: [email protected]
115
116
Editorial
matization is less a denial of underlying "psychological lesions" than a locally appropriate strategy of engaging physicians' concern. In developing countries such as China where practitioners have neither time nor expertise for conducting psychotherapy, patients' selectively amplifying somatic distress and silencing affectivity is a form of help-seeking behavior that may simply reflect the norms and values of the health care system--in this case, the culture of overcrowded out-patient clinics where somatization is a passport to soliciting time-saving pharmacotherapy. So, somatization among most Chinese patients is best considered a co-creative process that involves physicians as much as patients positioned in particular sectors of a socioeconomically constrained health care system [5, 7]. Arguably, as Chinese society transforms as a result of changes linked to market economy, urbanization, and industrialization, and as demoralization begins to be appropriated in a less time-constrained therapeutic culture, patients' spontaneous expression of affectivity may become more common. The recent upsurge of interest in the diagnosis of depression (yiyu zheng) and psychological counseling (xinli zixun) in a number of rapidly developing cities in China [7] attests to this dynamic relationship between political economy and what medical anthropologists term "idioms of distress"; that is, culturally legitimate modes of signifying persohal distress and predicaments [2, 4, 6]. This is not to imply, of course, that the somatic presentation of distress will simply disappear. Because of the complexity of somatization in both theory and practice, the subsidiary concept of "somatoform disorders" is only a limited and limiting way of interpreting its cross-cultural variations and clinical salience. According to the ICD-10, the main features of such conditions are the repeated presentation of physical symptoms and persistent requests for medical investigations despite negative findings and reassurances by doctors that the symptoms have no physical basis. The patient usually resists attempts to discuss the possibility of psychological causation even in the presence of precipitating psychosocial stressors [8]. Embodying a Western reductionist epistemology, somatoform disorders arise from a highly reliability-driven nosology, which generalizes the medical model of mental disorders from major neuropsychiatric diseases to virtually all forms of human suffering and behavioral deviance. The hybrid (half-Greek and half-Latin) word "somatoform" is grounded in the intellectual legacy of mind-body dualism which is pervasive in Western philosophy [4]. It is alien to non-Western ethnomedical traditions which subscribe to a functional view of health and disease [9], according to which no ontological distinctions between psychiatric and nonpsychiatric, or authentic and less authentic diseases, are made. Strictly speaking, somatization is a Western cultural construction, whereas somatoform disorders enact a most radical, if not irrational, form of the mind-body discourse [7]. Not so surprisingly, Chinese psychiatrists who devised the CCMD-2-R are far from being impressed with the concept of somatoform disorders [4]. They find it a terminological puzzlement, much like Western psychiatrists may see "affectoform disorder" to be a neologism. Professor Y. X. Xu, a psychiatric luminary from Beijing, branded it as being obscure and misleading. In his view, Chinese patients willingly reveal dysphoria and usually acknowledge psychogenesis in the context of a sound doctor-patient relationship, suggesting that their somatic distress and psychic suffering are integrated, albeit loosely stitched and context-specific [10]. Cross-
Editorial
117
cultural and anthropological studies have affirmed that somatic symptoms are situated in multiple systems of meanings, can be symbolically interpreted, and serve psychosocial functions [1, 5-7]. From the point of view of patients and their significant others, no somatic symptoms are unexplainable. In this respect, the diagnostic emphasis on somatoform disorders being "medically unexplained" may be damaging to the doctor-patient relationship, as unwary practitioners mortify patients who seek specialist validation as having a less than authentic if not fictive ("It's all in your head") illness [5]. Somatoform disorders may face further problems when they are applied to China's vast agrarian and/or illiterate populations, who do not necessarily entertain the concept of functional versus organic mental disorders [9]. As medical investigations are often unavailable in their modest treatment locales, health practitioners frequently cannot ascertain whether patients' somatic symptoms are truly "medically unexplained." Because rural people are unfamiliar with biotechnological explanatory models of disease, few of them exhibit "persistent requests for medical investigations" as Anglo-American patients who are often enthused about the latest findings in clinical trials may apparently do. And when they consult traditional healers who do not make an ontological distinction between the physical and the psychological, it is unclear how the diagnostic requirement that "reassurances by doctors that the symptoms have no physical basis" (italics added) [8] could be meaningfully applied. In his commentary of international psychiatric nosology, Xu therefore admonished that the ICD-10 has unwisely borrowed the term somatoform disorder from the DSM-III-R, and that its widespread use in China may lead to inappropriate diagnosis and treatment [10]. It is perhaps no coincidence that criticisms of the concept have also been raised by Tyrer, who noted that "the introduction of the term somatoform disorders has been an American initiative, and the ICD-10 has been, somewhat reluctantly, carried in its wake" [11]. Likewise, most Japanese psychiatrists "indicated reluctance to the partitioning of neurotic disorders into anxiety, somatoform, and dissociative disorders in DSM-III, and preferred the ICD-9 classification of neurotic disorders" [12]. Clinical syndromes characterized by a varying syncretism of somatic and emotional (for example, anger, anxiety, depression, emptiness, fear, and irritability) symptoms exist panculturally and have been variously named, for example, shenjing shuairuo (neurasthenia) in China, dhat in India, shinkeishitsu in Japan, hwa-byung in Korea, shenkui in Taiwan, brain fag in Eastern Africa, and ataques de nervios in Puerto Rico [5, 6]. After mood and anxiety disorders are excluded by hierarchical criteria, they can usually be "somatized" into the category of undifferentiated somatoform disorder [7]. However, to the extent that the human body in these societies is symbolically elaborated and somatic distress has multiple layers of meaning, the somatoform label runs the risk of rendering invisible the cultural forces in these popular indigenous syndromes that powerfully shape the local worlds in which patients' suffering is negotiated and contested. For example, a study of Chinese patients with a CCMD-2-R diagnosis of neurasthenia in Hong Kong revealed that, after mood and anxiety disorders were excluded, most of them could be "forced" to receive a diagnosis of undifferentiated somatoform disorder or somatoform pain disorder. But, by focusing exclusively on somatic symptoms and by requiring the failure to recognize psychosocial causes as a crucial clinical feature, these categories
118
Editorial
did violence to patients' variegated symptom profiles and their narration in a network of cultural conflicts which characterize everyday life in contemporary Hong Kong. Their experience-distancing nature is particularly obvious when, say, undifferentiated somatoform disorder is translated as wei fen hua qu ti zhangai, which is unidiomatic and barely intelligible to Chinese people, including mental health professionals [7, 13]. Notwithstanding the hegemony of official nosology, which looms behind clinicians' thinking and practice, somatoform disorders have been found to be difficult to apply by psychiatrists (not to speak of general practitioners) in Taiwan, Hong Kong, and China, where neurosis, neurasthenia, hypochondriasis, mild anxiety, and depressive disorders are commonly used diagnostic labels [4, 13]. In fact, somatoform disorders do not seem to be a valid diagnostic category for the majority of Western patients who fall short of the criteria for mood and anxiety disorders in primary care. Based on data from the DSM-IV field trial for mixed anxiety-depressive disorder in the USA, the proposal has therefore been made that this category be reconsidered for inclusion in future versions of the DSM system [14]. Its symptom configuration, namely, a core symptom of nonspecific dysphoria and a varying mixture of somatic and cognitive symptoms, closely resembles the CCM49-2-R definition of neurasthenia in China [13]. This timely proposal attests to a genuine need for a flexibly construed somatoaffective category in both Western and non-Western nosological systems. By reuniting mind and body in clinical theory and practice, this category also encourages a useful critique of certain abiding assumptions of the DSM-IV and ICD-10 systems, such as the cultural validity of diagnostic constructs and syndromic architectures derived from an adamant adherence to the mind-body dichotomy [4]. This is not to say that somatoform disorders are no more than an imaginary disease category. But evidence is unconvincing that, after mood and anxiety disorders are systematically excluded, they constitute the next most prominent form of psychiatric disorder in any society. Future revisions of the DSM-IV or ICD-10 may retain them as a residual category, but only after somatoaffective syndromes (which may be subcategorized according to the local context) are excluded. Far more important than diagnostic controversies, effective modes of intervention for the enormous number of people who suffer from somatoaffective syndromes across all cultural groups and societies must be promptly identified. As more psychiatric treatment is predictably incorporated into primary care and as medical service becomes increasingly insurance-driven, it is necessary to explore novel and cost-effective treatment methods, such as short-term group therapy [15]. Because patients with somatoaffective syndromes do seem to benefit from "alternative" therapies, there is an urgent need to evaluate, by combining biomedical and social science methodologies, the efficacy of such methods of treatment as homeopathy, Ayurveda, and traditional Chinese medicine [16-18]. These approaches to healing do not marginalize "unexplained" somatic symptoms; integrate somatic, social, and moral therapies,, and manipulate placebo effects to patients' satisfaction [9]. They may also be integrated with allopathic methods of treatment. In China, for example, herbal tablets are sometimes prescribed along with tricyclic antidepressants for patients with depression and/or neurasthenia, partly for modulating the latter's therapeutic and side effects. The efficacy of such "holistic" methods of treatment such as
Editorial
119
acupuncture and qigong (a trance-based form of Chinese healing exercise) in the management of chronic pain and insomnia similarly warrants more empirical investigation [17]. Inasmuch as somatic symptoms may also represent a sociomoral medium for protest against inequities and a strategy for social repositioning [1, 5], an effective paradigm of care must ultimately restructure state policies and encompass socially meaningful forms of empowerment for the disenfranchised members of society. This may mean, for example, more nurseries and public housing for lower social class couples in Hong Kong, more education for women in rural China [7], and more jobs for people in societies with high rates of unemployment. In an era when health care is dictated by economic concerns, to do this is to devise ways of convincing physicians, policymakers, and politicians that health care is not just a human right, but also a way of increasing human capital [19].
REFERENCES 1. Kleinman A, Kleinman J. Remembering the cultural revolution: alienating pains and the pain of alienation/transformation. In: Lin TY, Tseng WS, Yeh EK, eds. Chinese societies and mental health. Hong Kong: Oxford University Press 1995:148. 2. Kleinman A. Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry 1982;6:117-190. 3. Hwu HG, Comptom WM. Comparison of major epidemiological surveys using the diagnostic interview schedule. Int Rev Psychiatry 1994;6:309-327. 4. Lee S. Cultures in psychiatric nosology: the CCMD-2-R and international classification of mental disorders. Cult Med Psychiatry 1996;20:421--472. 5. Kirmayer LJ, Young A. Culture and somatization: clinical, epidemiological and ethnographic perspectives. Psychosom Med (in press). 6. Kleinman A. How is culture important for the DSM-IV? In: Mezzich JE, Kleinman A, Fabrega H, Parron DL, eds. Culture & psychiatric diagnosis--a DSM-IV perspective. Washington, DC: American Psychiatric Press 1996:15-25. 7. Lee S. Estranged bodies, simulated harmony, and misplaced cultures: neurasthenia in contemporary Chinese society. Psychosom Med (in press). 8. World Health Organization. The ICD-10 classification of mental and behaviour disorders---clinical descriptions and diagnostic guidelines. Geneva: WHO 1992:161. 9. Fabrega H Jr. The concept of somatization as a cultural and historical product of Western medicine. Psychosom Med 1990;52:6534572. 10. Xu YX. About ICD-10. J Clin Psychol Med 1994;4:224-226 (in Chinese). 11. Tyrer P. Classification of neurosis. Chichester, UK: Wiley 1989:92. 12. Yamashita I, Koyama T. Neurotic spectrum disorders in Japan. In: Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric diagnosis: a world perspective. New York: Springer, 1994:97. 13. Lee S. The vicissitudes of neurasthenia in Chinese societies: where will it go from the ICD-10? TPRR 1994;31:153-172. 14. Zinbarg RE, Barlow DH, Liebowitz M, Street L, Broadhead E, Katon W, Roy-Byrne P, Lepine JP, Teherani M, Richards J, Brantley PJ, Kraemer H. The DSM-IV field trial for mixed anxiety-depression. Am J Psychiatry 1994;151:1153-1162. 15. Kashner TM, Rost K, Cohen B, Anderson M, Smith GR Jr. Enhancing the health of somatization disorder patients. Psychosomatics 1995;36:462-470. 16. Zhou K, Shu F, Chen JX, Xu SH, Zhou CF, Xu PJ, Shi L, Sang NJ. A controlled study of combination treatment of neurasthenia classified by traditional Chinese medical criteria. Chin J Neurol Psychiat 1986;19:306-308 (in Chinese). 17. McNamara S, Song XK. Traditional Chinese medicine. London: Hamish Hamilton 1995. 18. Li QF, Liu DZ, eds. Psychiatry in traditional Chinese medicine. Tienjin: Tienjin Publishing House of Science and Technology 1989 (in Chinese). 19. Desjarlais R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford: Oxford University Press 1995.