I

Distress and disability

_ Social response -

Figure 3 A multifactorial model of somatization (based on Kirmayer and Taillefer (1997)).

somatoform illness requires a theoretical approach that is specific to this form of somatization—an approach that is inherent to dissociation and conversion models.

Second, the model of somatization described here assumes that medically unexplained symptoms are necessarily the product of physiological processes, such as the physical components of emotional states, and minor pathological events. Although such processes might play an important role in the generation of certain somatoform symptoms, it is difficult to understand how unexplained neurological (i.e., conversion) symptoms can be explained in this way.

Third, as with theories based on the concepts of conversion and dissociation, the somatization model assumes that unexplained symptoms are necessarily the expression of psychological distress. Although this may be true in many cases, particularly those associated with anxiety, depression, or hypochondriasis, it is apparent that such an assumption may be inappropriate in many other cases.

Finally, it may be misleading (and, indeed, pejorative) to identify somatoform illness as necessarily involving ''abnormal'' illness behavior. In our view, seeking help for subjectively compelling and debilitating symptoms is more appropriately regarded as normal illness behavior, regardless of whether an underlying pathophysiological basis for those symptoms can be found. Similarly, it is unclear what constitutes a ''normal'' illness response to repeatedly negative physical investigations despite the persistence of symptoms, particularly when disability is high (e.g., as in paralysis). As such, it may be more appropriate to reserve the concept of abnormal illness behavior for those cases in which the problem appears to involve more than just a poor doctor-patient relationship or the presentation of unexplained symptoms per se.

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