A Reconceptualization of the Somatoform Disorders

RUSSELL NOYES JR., M.D.

SCOTT P. STUART, M.D.
DAVID B. WATSON, PH.D.

Since its introduction in DSMIII, the Somatoform Disorders category has been a subject of controversy. Critics of the grouping have claimed that it promotes dualism, assumes psychogenesis,
and that it contains heterogeneous disorders that lack validity. The history of these disorders is
one of shifting conceptualizations and disputes. A number of changes in the classification have
been proposed, but few address problems that arise with the current formulation. The authors
propose a dimensional reconceptualization based on marked and persistent somatic distress and
care-eliciting behavior. This formulation is based on the interpersonal model of somatization.
The authors propose testing of this conceptualization and indicate how this might be done.
(Psychosomatics 2008; 49:1422)

he framers of DSMIII took the hysterical and hypochondriacal neuroses from earlier versions and created a new category: the somatoform disorders.13 Many
have regarded this new grouping as unsatisfactory and
have offered various solutions to the problems they see,
including elimination of the category altogether.4 As the
time for DSMV approaches, debate about these disorders is intensifying, and impetus for change is growing.57
In this article, we review problems with the classification
of somatoform disorders in DSMIV, the background and
development of this classification, and solutions proposed
for DSMV. We then offer a reconceptualization and suggest how this new model might be tested.
Problems With the Current Classification
Critics claim that the Somatoform Disorders section of
DSM promotes mindbody dualism.8 Defined in terms of
Received February 6, 2007; accepted February 9, 2007. From the Dept.
of Psychiatry, Carver College of Medicine, and the Dept. of Psychology,
College of Liberal Arts and Sciences, Univ. of Iowa, IA City, IA. Send
correspondence and reprint requests to Russell Noyes, M.D., Psychiatry
Research, Medical Education Building., Univ. of Iowa, IA City, IA
52242-1000. e-mail: russell-noyes@uiowa.edu
2008 The Academy of Psychosomatic Medicine

14

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physical symptoms, the somatoform disorders are regarded

as psychological in nature because no organic disease explains them. Consistent with biomedical theory and practice, they are viewed as non-legitimate disturbances for
which patients themselves are responsible.9 Hence, patients
with such disorders are seen as the province of psychiatry,
rather than general medicine.
Some claim that patients who are ill but without disease
pose a threat to Western biomedicine.10 They say that, to
maintain this system, it is necessary to devalue and stigmatize such patients.11 Although patients with psychiatric
disorders generally are stigmatized, those with somatoform
disorders are singled out because these disorders masquerade as physical conditions.12 Critics contend that such disorders do not assume recognizable form in cultures lacking
this dualism. They see them as creations of dualistic thinking.13
Somatoform Disorders in DSMIV involve conceptual ambiguity.4 Individual disorders are conceptualized in
terms not only of somatic distress but also an absence of
organic disease and failure to respond to medical care. A
diagnosis of hypochondriasis, for instance, requires a patient to have been evaluated by a physician, found to be

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Noyes et al.
without physical explanation for their symptoms, and to
have resisted appropriate reassurance.3
The somatoform disorder categories are criticized for
lack of validity.14 Diagnostic categories are regarded as
valid if they have been shown to be discrete entities with
natural boundaries that separate them from other disorders.15 There have been few studies of clinical features,
biological markers,16 family aggregation,17 longitudinal
course, or treatment response.18 However, few psychiatric
diagnoses are valid by the above criteria, so the somatoform disorders are not alone. Still, many diagnoses have
high utility because they convey information about etiology, outcome, and treatment response.15 This kind of utility
is generally lacking for the somatoform disorders. Such
diagnoses are rejected by patients who see their problems
as physical. Also, the rarity of these disorders, as currently
defined, does not reflect the level of somatic distress encountered by clinicians.4,19
Finally, the somatoform disorders are heterogeneous
and lack clear definition.4 All have extensive Axis I, Axis
II, and Axis III comorbidity, and exclusionary rules regarding coexisting disorders are not clear. Also, the thresholds set for various disorders are either too low (e.g., Pain
Disorder) or too high (e.g., Somatization Disorder).20,21
The classification of functional somatic syndromes (e.g.,
irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome) is an unsolved problem.22 These disturbances have unexplained symptoms, yet are classified by
nonpsychiatric physicians according to a competing system
that may have greater acceptance and utility.
These criticisms call for a reexamination of existing
models and reclassification of the somatoform disorders.
Before reviewing the proposed reconceptualization of the
category, let us consider some historical background.
Historical Background
Hysteria and hypochondriasis have been recognized since
antiquity. Both were ill-defined disorders, characterized by
multiple physical as well as psychological symptoms, especially depression. They had little resemblance to presentday disorder classifications that only began to emerge in
the eighteenth and nineteenth centuries as diseases with
anatomical pathology were identified. Hysteria, the forerunner of somatization disorder, was attributed to wanderings of the uterus.23 Hypochondriasis was related to
disturbance of upper abdominal organs, especially the
stomach and spleen.24
During the 19th century, hysteria and hypochondriasis,
Psychosomatics 49:1, January-February 2008

which had once been frequent diagnoses, all but disappeared as organic diseases were removed from the respective categories.25 For hysteria, these included tertiary syphilis and epilepsy, and, for hypochondriasis, they included
gastrointestinal diseases. Toward the end of the century,
hypochondriasis was subsumed under the broad category
of neurasthenia, although it later reemerged as something
distinct.26 At the same time, Hysteria was popularized by
Charcot, and it became a concern of psychoanalysis. According to Breuer and Freud,27 mental distress might be
converted into physical dysfunction symbolic of that distress. Consequently, such functional neurological disturbances became known as conversion symptoms.
Conversion reaction characterized by functional neurological symptoms was included in DSMI,1 but hysterical and hypochondriacal neuroses did not appear until
DSMII.2 Hysterical neurosis, an acute reaction to stress,
consisted of involuntary loss, or disorder of, function. Hypochondriacal neurosis was dominated by preoccupation
with the body and fear of presumed disease of various organs.
DSMIII3 added a chronic form of hysteria, labeled
Somatization Disorder. In DSMIII, explicit criteria were
introduced, and a new group of somatoform disorders was
created. The essential feature was physical symptoms suggestive of a physical disorder (hence somatoform) in the
absence of organic disease and presence of psychological
factors. Criteria for somatization disorder were based on
the description of hysteria by Briquet28 and Purtell et al.29
These authors described a polysymptomatic syndrome in
women that began early in life and was characterized by
chronic ill health and complicated medical history, presented dramatically. Guze30 and others showed that this
diagnosis was stable over time, that the disorder remained
chronic, and that it occurred in female family members.
Criteria for hypochondriasis were based on the description
of Gillespie,31 who defined it as a mental preoccupation
with a real or supposititious physical or mental disorder.
Other disorders included in the somatoform category were
conversion disorder and psychogenic pain disorder.
A number of modifications to the somatoform criteria
were made in DSMIII-R and DSMIV.32,33 First, several
categories were added. Undifferentiated Somatoform Disorder is characterized by unexplained physical symptoms
falling below the threshold for somatization disorder. Also,
Body Dysmorphic Disorder was added, as was a residual
category, Somatoform Disorder, Not Otherwise Specified.
Because the DSMIII Somatization Disorder criteria were
difficult to apply, they were simplified for DSMIV, which
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Somatoform Disorders
now requires a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms. Conversion Disorder in DSMIV is more narrowly defined as symptoms
affecting voluntary motor and sensory functions, rather
than any symptom suggestive of a physical disorder. The
criteria for Pain Disorder were modified to include subtypes.34 These now include Pain Disorder 1) Associated
With Psychological Factors; 2) Associated With Both Psychological Factors and a General Medical Condition; and
3) With a General Medical Condition alone. Several
changes in the criteria for Hypochondriasis were also
made. DSMIV stipulates that the belief concerning serious disease is not delusional. The disturbance must have
lasted 6 months and must not be due to an anxiety, depressive, or other somatoform disorder. Also, separate criteria for Specific Phobia, Other Type (illness) were introduced.35 Illness-phobic patients are said to fear contracting
a serious illness, whereas hypochondriacal patients believe
that such illness already exists.
The ICD10 Somatoform Disorder criteria differ from
those in DSMIV in several important respects.36 In ICD
10, body dysmorphic disorder is incorporated in the criteria
for Hypochondriasis. Also, the ICD10 includes a category
called Somatoform Autonomic Disorder. The criteria call
for symptoms of autonomic arousal in the absence of any
disturbance of structure or function. The criteria for somatization disorder are less restrictive, calling for at least
2 years of multiple and variable unexplained symptoms
representing at least two organ systems. The ICD10 criteria for Pain Disorder call for persistent, severe, and distressing pain (continuously for at least 6 months) that cannot be explained by a physical condition. DSMIV, by
contrast, specifies an important role for psychological factors, but has no duration requirement.
Alternatives to the Current DSM Classification
A number of authors, beginning with Mechanic,37 have
focused on illness behavior. Such behavior is appropriate
for a person with physical disease occupying the sick
role.38 However, when such disease is lacking, it may be
viewed as abnormal.39 According to Bass and Murphy,40
behavior of this kind may be a manifestation of disordered
personality. As they see it, somatoform disorders are best
conceptualized as personality disturbances. Consistent with
their view, these disorders have an early onset and lifelong
pattern of interpersonal difficulties with caregivers and attachment figures. Also, high rates of personality disorders
have been observed among somatoform patients.41,42
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Along similar lines, Stuart and Noyes43 have proposed

an interpersonal model for somatization. According to this
model, somatic symptoms represent care-seeking behavior
on the part of individuals with insecure attachment. They,
like Bass and Murphy,40 point to the importance of developmental factors both for shaping personality and for directing attention toward somatic symptoms. Experience
with illness in oneself or ones family may be an important
causal factor.44,45 These authors would also classify the somatoform disorders among the disorders of personality or
attachment style.
Stress-diathesis modeling provides yet another conceptualization for somatization and somatoform disorders.46 According to this model, some patients are vulnerable to somatic distress by virtue of their psychological
make-up; they deviate from the norm on one or more psychological dimensions. Pennebaker and Watson,47 in their
review of the literature, found strong and consistent evidence linking symptom-reporting and hypochondriacal
worry to neuroticism or negative affectivity. Neuroticism
is the major personality dimension included in virtually all
trait models. Persons who score high on this dimension
experience and report negative emotions and overreact to
stress. In their model of somatization, Kirmayer and Taillefer48 included such additional factors as attentional set,
coping style, and autonomic reactivity. Along similar lines,
Cloninger et al.49 see the development of a somatoform
disorder as part of a complex adaptive process involving
nonlinear interactions among multiple contributing factors. They note that patients with somatization disorder
are likely to have borderline personality traits and be high
on harm-avoidance and novelty-seeking.
McHugh and Slavney50 offer a different conceptualization. For them, hysteria (somatization disorder) is a disturbance of goal-directed behavior and should be classified
as such. It is not something a person has but something a
person does. It is an imitation of physical conditions by
persons who believe they suffer from some disease. The
goal of their behavior is to persuade others that they are
ill.51 The factors that provoke this behavior are those that
may find solution in adoption of the sick role or in publiclyacknowledged disability.52 McHugh53 proposed an idiopathic classification of psychiatric conditions composed of
four clusters of disorders. One of these clusters is made up
of patients who adopt fixed, maladaptive behaviors (i.e.,
substance abuse, eating disorders, somatization disorder,
etc.).
Another proposal calls for elimination of the Somatoform category in DSMV.4 In addition to the problems
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Noyes et al.
outlined earlier, proponents note that this heterogeneous
grouping is based on clinical considerations (i.e., the need
to exclude physical conditions), rather than on similarities
between individual disorders or shared mechanisms.54
Once eliminated, the disorders within this category might
be reassigned. For instance, Conversion Disorder appears
to share essential features with the dissociative disorders
and might be moved to that section.55 Hypochondriasis
might be relocated to the anxiety disorders (health-anxiety
disorder) or placed within an obsessive-compulsive spectrum.7,56 Body Dysmorphic Disorder might also be reclassified within such a spectrum, although the disorder remains ill-defined, and evidence for it is inconsistent.57
Somatization Disorder might be reclassified among the unstable (Cluster B) personality disorders.56
Some advocate less-radical modifications to the existing classification. Rief and Sharpe,58 for instance, call for
a broader conceptualization, especially of somatization disorder. This disorder is presently defined only by the type
and number of somatic symptoms. Excluded from the criteria is any mention of emotions, beliefs, and behaviors
that define most mental disorders. These authors call for
adding such characteristics (e.g., illness attribution, attentional focus, symptom amplification, illness behavior) either within the present system or by modifying it to include
new axes.59 Other proposals involve alternative definitions
of individual disorders, especially somatization disorder.
For example, Fava et al.,60,61 have offered diagnostic criteria for a series of psychosomatic syndromes occurring in
association with medical conditions, not separate from
them. Alternative definitions for several DSM and ICD somatoform disorders are included. Similarly, Martin64 proposed a diagnostic scheme linking somatoform disorders
to psychosocial stressors. In different ways, these alternatives attempt to bridge the mindbody separation.
Efforts have also been made to redefine individual disorders, especially somatization disorder and hypochondriasis, so as to include more of the somatically distressed
population.63 As defined in DSMIV, they are rare. To address this concern, Escobar et al.,64 among others, have
proposed criteria for an abridged somatization disorder
category, based on fewer somatic symptoms than were required for the DSMIII Somatization Disorder diagnosis.
Kroenke et al.21 developed criteria for multisomatoform
disorder. These require a number of unexplained symptoms, as well as at least 2 years of multiple somatoform
symptoms. When these modified criteria have been applied, the prevalence of somatization or multisomatoform
disorders has substantially increased, whereas the extent of
Psychosomatics 49:1, January-February 2008

functional impairment and healthcare utilization have remained much the same. With respect to hypochondriasis,
Guerje et al.65 observed that, if the criterion of failure to
respond to reassurance were set aside, the prevalence
would increase considerably, yet the patient characteristics
would remain unchanged. Furthermore, Looper and Kirmayer66 found that persons who had persistent illnessworry, but who did not meet criteria for hypochondriasis
were, nevertheless, distressed and impaired.
Proposed Reconceptualization
We propose a reconceptualization of the somatoform disorders, as outlined in Table 1. This new framework has five
features, the first two of which are specific for individual
diagnoses. First, any formulation for the grouping must
begin with somatic distress. Such distress may take varied
forms. As indicated by Hiller and Rief,67 four types of
clinical presentations should be covered by the generic
term. Included are patients who 1) suffer from multiple
symptoms in different parts of the body (polysymptomatic); 2) suffer from only one symptom in a single organ
system (monosymptomatic); 3) experience health-anxiety
or disease-conviction as the prominent feature (hypochondriasis); and 4) are excessively concerned about the appearance of their body (body dysmorphic disorder). All
these types are included in the first item.
The second feature is related to the first. Somatic distress is associated with care-eliciting behaviors that are focused upon it. Such illness behaviors, which are prominent
among somatoform disorders, may take a variety of forms
that include persistent seeking of reassurance, sick-role
privileges, and medical care. These behaviors are directed
toward healthcare providers as well as others in the individuals social network. They may or may not have their
basis in recognized medical conditions, but it is their
marked and persistent nature, not their origin, that characterizes them.
TABLE 1.

Framework for a Reconceptualization of

Somatoform Disorders

1. Marked and persistent distress related to, and preoccupation

with, physical symptoms, illness, defect, or impairment.
2. Marked and persistent illness behavior related to physical
symptoms, illness, defect, or impairment.
3. The somatic distress and illness behavior cause impairment in
physical, occupational, or interpersonal functioning.
4. The disturbance is chronic.
5. The distress is not better accounted for by other psychiatric
disorders.

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The third feature makes specific mention of areas of
dysfunction characteristic of somatoform disorders. Physical impairment often extends to work or employment (e.g.,
reduced efficiency, lost work-days), and interpersonal impairment may include interactions with medical professionals. The doctorpatient relationship is often strained,
and doctor-shopping may occur.68
The fourth feature indicates that the disorders are
chronic, and the fifth covers exclusionary criteria for other
psychiatric disorders.
Some of the current somatoform disorders fit this conceptualization better than others. Conversion symptoms
tend to be acute, and so may fall outside the framework of
chronic disturbances outlined here.69 Hypochondriasis involves abnormal emotions and beliefs as well as prominent
somatic distress.70 The focus of distress in body dysmorphic disorder is on perceived defects in appearance.
Although our proposal specifically mentions defects, its inclusion would require empirical support.71 Pain disorder,
as well as conversion disorder, represent monosymptomatic somatoform disorders.72
Table 2 displays proposed diagnostic criteria for hypochondriasis (health-anxiety disorder) and somatization
disorder. They are, in many respects, contrasting conditions, and their criteria include contrasting clinical features:
for hypochondriasis, persistent reassurance-seeking, and,
for somatization disorder, persistent care-rejection.73 Criteria for other disorders might be drafted by use of the same
format.
The proposed criteria do not mention any response to
medical care (i.e., failure to respond to reassurance) of the
sort found in DSMIV Hypochondriasis.33 As indicated,
the current criteria have been criticized for this inclusion.
Similarly, the proposed criteria do not state that symptoms
are unexplained, as is the case in DSMIV Somatization
Disorder.33 There are several reasons for this. First, this is
an unclear distinction, which has been found to have little
TABLE 2.

significance or empirical support.74 Fink et al.75 have demonstrated that valid criteria for hypochondriasis do not require this kind of medical information. As these authors
showed, characteristic forms of somatic distress and illness
behavior appear sufficient for somatoform diagnoses even
in the presence of organic disease. Second, disorders
should be defined in terms of features that are present, not
those that are absent. Third, saying that symptoms are unexplained implies a failure to conform to biomedical theory, according to which, illness must correspond to underlying disease.58 Such failure is not a satisfactory basis for
classification.
The proposed conceptualization has several advantages. First, it reflects a biopsychosocial, rather than the
more restrictive biomedical, model. The biopsychosocial
formulation does not artificially separate mind from body,
a division that has plagued conceptualization of the somatoform disorders. Second, the disorders are not defined
by an absence of organic disease; similarly, they are not
defined by inappropriate response to medical treatment. Instead, they are characterized by persistent health preoccupation and care-seeking behavior, irrespective of the legitimacy of the patients physical condition. Third, the
proposed conceptualization appropriately emphasizes behavioral disturbances. Many have noted the prominence of
personality and interpersonal problems among somatoform
patients.40,41 These features make for more reliable and
easily understood criteria. Finally, this conceptualization is
dimensional; implied is the notion that somatic distress and
illness behavior represent exaggerations of the normal. Somatoform disorders are, therefore, deviations of quantity,
not quality.
Still another advantage is that our proposed conceptualization conforms to the interpersonal model of somatization. According to this etiologic model, individuals
with somatoform disorders manifest care-eliciting behavior
stemming from insecure attachment.43 Evidence for this

Proposed Criteria for Hypochondriasis and Somatization Disorder

Hypochondriasis (Health Anxiety Disorder)

1. Marked and persistent preoccupation with fear of having, or belief that one has, serious illness.
2. Marked and persistent reassurance-seeking or checking behavior.
3. The preoccupation with serious illness and reassurance-seeking behavior cause impairment in physical and interpersonal functioning.
4. The disturbance is chronic.
5. The preoccupation and reassurance-seeking are not better accounted for by other psychiatric disorders.
Somatization Disorder
1. Marked and persistent preoccupation with multiple somatic symptoms and physical disability.
2. Marked or persistent demands for, yet rejection of, health-related care and concern.
3. The preoccupation, as well as demands for, and rejection of, care cause impairment in physical and interpersonal functioning.
4. The disturbance is chronic.
5. The preoccupation, as well as demands for, and rejection of, care are not better accounted for by other psychiatric disorders.

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Noyes et al.
model has been accumulating. Specifically, a number of
recent studies have found associations between insecure
attachment styles and reporting of somatic symptoms.7679
Also, several studies have demonstrated relationships between various forms of insecure attachment and hypochondriacal concerns.78,80,81 Both clinical impression and
investigation point to distinctive attachment styles associated with hypochondriasis and somatization disorder; that
is, preoccupied and dismissive, respectively. This is a testable model for which evidence already exists, and it moves
us closer to an etiologically-based classification.
Testing the Model
In testing the proposed model, there are several questions
to be answered: First, do the somatoform disorders share
combinations of somatic distress and care-seeking behavior as specified by this model? Care-seeking behavior is
observed in insecurely attached individuals, especially
when relationships are threatened by illness.82 Consequently, various attachment styles may be linked to one or
another form of somatic distress, and such links might be
demonstrated.83 Likewise, personality deviations, such as
high neuroticism and low agreeableness, which are associated with interpersonal difficulties and unsatisfactory relationships with caregivers, may be closely related to somatic distress.84
Second, do the criteria distinguish individual somatoform disorders from each other?75,85,86 There is evidence
that hypochondriasis is a multidimensional construct that
includes illness-fear, illness-belief, somatic preoccupation,
and interpersonal alienation.87 There is also evidence of
associations with neuroticism and preoccupied attachment
style.81 Somatization disorder, in contrast, appears to comprise multiple somatic symptoms and Cluster B (especially
borderline) personality traits.88 Clinically, a dismissive attachment style has been observed in patients with this disorder. A review of the preliminary evidence suggests that,
in many respects, these are contrasting disordersone, externalizing and the other, internalizing.85 For example,
Leibbrand et al.86 compared patients with DSMIV Hypochondriasis and DSMIV Somatization Disorder with
respect to symptoms and personality traits. They found
that, despite the overlap in these diagnoses, they were distinguishable on self-report measures.
Third, do instruments exist with which to assess the
critical dimensions that define the somatoform disorders?89,90 Dimensions that appear most relevant to our proposed reformulation include somatic distress, attachment
Psychosomatics 49:1, January-February 2008

style, personality, illness behavior, cognitive dysfunction,

and emotional disturbance. Within each of these, there are
likely to be sub-dimensions. For instance, somatic distress
may take a variety of forms, including pain symptoms,
pseudoneurological (conversion) symptoms, autonomic
symptoms, gastrointestinal symptoms, defects of appearance, functional impairment, and so on.9193 Similarly,
there are a number of attachment styles and personality
dimensions that have been linked to somatic distress of one
kind or another. However, in many instances, the available
research offers little guidance. Because it will be important
to distinguish somatoform from non-somatoform dimensions, measures of psychological symptoms and symptoms
due to physical conditions also must be included.94
Some instruments for the various dimensions within
our reconceptualization currently exist, whereas others
may need to be developed. Hiller and Janca95 have reviewed the available measures for somatoform disorders.
Many are multidimensional, especially those for the evaluation of hypochondriasis. In addition to the self-report
instruments, there are a number of structured, observerrated interviews and checklists that include, or are designed
specifically for, somatoform disorders. Hiller and Janca95
note that available instruments are strongly influenced by
the current DSM and ICD classifications, and, therefore,
reflect many of the problems discussed earlier.
These problems highlight the need to develop a new
generation of assessment instruments to measure the key
components of our reformulation. A detailed discussion of
this issue is beyond the scope of this article, but we note a
few basic considerations here. First, no existing instrument
contains allor even mostof the basic elements in our
reformulation. Indeed, we currently lack reliable and valid
measures for several aspects of this model. Accordingly,
there is need for a new assessment strategy that carefully
assesses all of these elements within a single framework.
This integrated approach would allow us to clarify the
structure of this domain (e.g., the existence of subtypes of
somatic distress) and to explicate the nature of associations
among its various elements. Second, following established
principles of instrument development,96 any new instrument should be over-inclusive. That is, it should not be
restricted simply to the elements contained in our model,
but also should include dimensions from other recently
proposed reformulations of this domain.
Furthermore, we should acknowledge several basic
challenges for assessment in this area. First, the reporting
of various somatic symptoms, fears of illness, help-seeking
behaviors, and so on, may be confounded by physical conhttp://psy.psychiatryonline.org

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Somatoform Disorders
ditions. The validity of the Illness Behavior Questionnaire
has been, for example, criticized on this basis.97 Among
other things, this underscores the importance of including
measures of current physical conditions in any comprehensive assessment. Similarly, somatoform dimensions are
strongly influenced by psychological distress, in the form
of depression and anxiety. Clearly, these types of psychopathology need to be modeled, as well. Moreover, it is not
clear whether patients can determine which somatic symptoms are unexplained. Similarly, it is not clear how reliable
somatoform patients may be when assessing their symptoms and behaviors. On the basis of these considerations,
it seems unlikely that simple self-report measures will be

able to assess all of the elements of our model. At the very

least, these types of measures will need to be supplemented
by interviews or other approaches.
CONCLUSION
Marked and persistent somatic distress, together with careeliciting behavior, is prevalent and poses a challenge to the
medical care system. The classification of patients with
such distress remains problematic, and their treatment is
still unsatisfactory. This situation calls for redoubled efforts
to reexamine and test various conceptual models of these
conditions.

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