To demonstrate the clinical usefulness of conceptualizing certain medical and psychiatric illnesses as disorders of affect regulation, we begin with the extremely common but poorly understood problem of patients who seek medical care with persistent somatic symptoms and little or no identifiable disease. Such patients typically present initially to primary care physicians, and are believed to account for as many as 10% to 30% of all visits to family doctors (Kellner, 1990). They are often misunderstood and unnecessarily referred to multiple medical and surgical specialists, which leads to over-investigation and excessive costs to the health care system (Bacon et al., 1994; Bass & Murphy, 1990; Shaw & Creed, 1991; Wickramasekera, 1989). Indeed, their use of inpatient and outpatient services is as much as nine times greater than that of the general population (Smith, Monson & Ray, 1986). When it becomes evident that no adequate medical diagnosis can be made for these patients, the persistent and puzzling somatic symptoms are usually attributed to somatization and described as ‘functional’ with the implication of an underlying psychiatric disorder.

Several studies have shown that many somatizing patients do in fact meet criteria for an anxiety disorder or a major depressive disorder (Bridges & Goldberg, 1985; Kirmayer & Robbins, 1991a); we will discuss this category of somatizing patients in Chapter 7.