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In a survey of international use of DSM-III and DSM-III-R, so-matoform disorders were among the more problematic diagnoses (Maser et al., 1991), probably because of their cross-cultural limi-tations (Kirmayer and Weiss, 1997). First, many nosologies around the world do not distinguish between mood, anxiety, somatoform disorders and dissociative disorders, because sufferers report sin-gle syndromes that run across boundaries of the diagnostic catego-ries (Lewis-Fernández, 1992). This is similar to the situation with depression, where a single description of the disorder has led to under-recognition and misidentification of depressive syndromes in many ethnocultural groups (Kirmayer and Groleau, 2001). Demarcating somatoform conditions in these settings may create artificial distinctions that confound accurate diagnosis. Examples include neurasthenia in China and other Asian settings, and nerv-ios in Latin America (Lin, 1989; Angel and Guarnaccia, 1989).
Secondly, the idioms of distress of many societies rely on somatic complaints for the expression of nonpathological, personal and social predicaments. Interpretations of these communication mechanisms as a somatoform disorder may result in overpathologization (Kirmayer and Robbins, 1991). In addition, the use of somatic idioms varies according to intracultural factors, such as gender and class, which in turn may determine who receives a somatoform diagnosis. For example, conversion symptoms appear to be more common in the rural and less educated sector of nonWestern societies, and particularly in family or social structures that allow few opportunities for protest (Kirmayer and Weiss, 1997; Nichter, 1981).
Thirdly, the symptom lists of DSM-III-R and DSM-IV-TR do not canvas the rich variety of somatic symptoms reported in other parts of the world, such as the complaints of worms and ants in the head described earlier (Ebigbo, 1982). Examples of other common somatic symptoms include chronic fatigue; heat in the feet, chest, or head; painful “gas’’ that moves from the abdomen around the flank to the back; “brainache’’; and feeling presences when alone or among others.
Fourthly, in most of the world, the degree to which symptoms are medically unexplained is difficult to ascertain owing to the marked limitation of diagnostic tests and medical personnel. Moreover, the high prevalence of endemic disease in the underdeveloped countries, often with protean and inchoate manifestations, may also confound the assessment of the somatoform disorders. This may result in overdiagnosis if organic causes are not identified, or underdiagnosis if organic explanations are uncritically accepted for systemic illness (Kirmayer and Weiss, 1997
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