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I was particularly impressed by Sharpe, M. and Carson, A. (2001) "Unexplained" somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Annals of Internal Medicine 134: 926-930. There is a lot to think more about here, starting with

"Patients seek help from physicians for symptoms. Physicians diagnose diseases to explain the symptoms. Symptoms are the patient's subjective experiences of changes in his or her body, whereas diseases are objectively observable abnormalities in the body. Difficulties arise when the physician can find no pathologically defined disease to explain a patient's somatic symptoms. These symptoms are referred to as poorly understood, or "unexplained," functional or somatization symptoms."

The distinction between "symptoms" and "disease" seems to me a terribly important one, and not only in cases currently labelled "psychosomatic" or "all in the head." An important generalization from contemporary work on the brain, phantom limb phenomena being one striking example, is that ALL "symptoms" are in fact "in the head". Discomfort and pain are not ever simply effects of disease or other disturbance of the body outside the brain. They are ALWAYS interpretations by the brain and so may or may not have origins in the body outside the brain.

So yes, indeed, we need a "paradigm shift," and its helpful along these lines to be reminded, as Sharpe and Carson have done, of some of the history of modern conceptions of symptoms, diseases, and the relation between them. "We need to rekindle the interest of the medical community ... in what is a substantial but neglected area of medical practice": "the psychologically augmented medical consultation".

We need as well changes in research agendas so as "to continue to explore the psychological mechanisms that produce symptoms but integrate these studies with biological investigations. The way in which psychological factors operate need not be cloaked under a mysterious process such as that suggested by 'somatization' but rather explicitly examined."

Most generally, we need to rethink presumptions we all have that create a sharp distinction between physical and mental health, and the associated research and therapeutic agendas associated with each. Recognizing that ALL symptoms originate in the brain seems to me a good starting point for this rethinking. If its all in the brain, then we should stop acting as if things "in the head" are less meaningful than things originating in the body outside the brain (see The Murky Politics of Mind-Body). All therapeutic practice should start with what's in the patient's head, moving from there to the rest of the body when it is helpful. And we, both researchers and patients, should recognize that much suffering and pain not only originates in the brain but has no explanation other than in the workings of the brain. Psychology is no longer distinct from biology, and what goes on in the brain is at least as important to human health as what goes on outside the brain.