Psychosomatics 43:437-440, December 2002
© 2002 The Academy of Psychosomatic Medicine
The Somatoform Disorders for DSM-V: The Need for Changes in Process and Content
Thomas N. Wise, M.D., and
Morten Birket-Smith, M.D., D.M.SCI.
Dr. Wise is Editor-in-Chief of Psychosomatics. Dr. Birket-Smith is from the Department of Psychiatry, Bispebjerg Hospital, Copenhagen. Please address all correspondence to Dr. Wise, Department of Psychiatry, Inova Fairfax Hospital, 3300 Gallows Rd., Falls Church, VA 22042.
Key Words: Somatoform Disorders • DSM
DSM-IV and its previous iterations have been described as "the triumph of nominalism (names have no reality over constituent words); over naturalism (names correspond directly to distinctions between natural kinds)."1 Much of the DSM owes its structure to the Washington University efforts to achieve diagnostic reliability so that valid entities could eventually be identified.2,3 Operational definitions of psychiatric disorders using a polythetic and multiaxial model have greatly enhanced this diagnostic process, although a search for validity continues. Unfortunately, the somatoform disorders continue to be problematic and need significant revision. In the text revision of DSM-IV (DSM-IV-TR), diagnoses in the somatoform disorder section share "the common feature...[of] the presence of physical symptoms that suggest a general medical condition."4 These disorders are demarcated from other psychiatric disorders, such as panic or depression, and are not due to medical conditions or substances that cause such physical distress. The somatoform disorders are particularly important in primary care settings, since individuals with psychiatric disorders frequently come to primary care settings with somatic complaints that are medically unexplained.5,6 Such medically unexplained complaints often denote psychiatric disorders. How to best categorize individuals who use the process of somatization (best defined as "a somatic idiom of psychosocial distress") is complicated.7,8 Both the process of the DSM work groups and the content of the somatoform section demand rethinking.
The development of each DSM iteration has utilized a governing board that appoints work groups organized around diagnostic groups. Each work group, composed of experts in the specific area, reviews the available literature as well as published and unpublished field trials of the diagnostic entities and develops both the operational criteria and accompanying text for the DSM publication. Prior to publication, the work group's draft is sent to a wide variety of consultants and advisors for comments. Professional organizations also review the draft iterations. A mandate for the current DSM iterations is to be consistent with the International Classification of Diseases (ICD) system.
Given the prevalence of somatoform disorders, it is remarkable that the work groups of DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR did not solely focus upon somatoform disorders but also addressed a variety of other disorders under the rubric of "interface conditions." A second process issue is the fact that within the interface conditions work group, members were solely from North America. Since much of the outstanding research in this area has been done by international contributors, as well as North Americans, it would seem reasonable to utilize such individuals in a more inclusive fashion than as "international advisors." Certainly, the DSM efforts have had major input from international nosology experts, but within the somatoform disorders section, there are dramatic absences. Individuals such as Christopher Bass, Per Fink, Giovanni Fava, Richard Mayou, Michael Sharpe, Wolfgang Rief, and Vladimir Starcevic, just to name a few, were not identified even as consultants9–15 In an era of e-mails, faxes, and international telecommunication, the inclusion of a broader range of experts is certainly appropriate.
The content of the somatoform disorders section is also problematic. Years ago, Fava et al.10 questioned whether the DSM-III-R nosology focused too much upon symptom counting in somatization disorder rather than the concept of abnormal illness behavior, which would also include hypochondriacal disorders. They also challenged the classification of conversion disorder. Subsequent researchers such as Schmidt16 have questioned the categorical basis for hypochondriasis. The DSM Sourcebook,17 which discusses the basis of any changes in each new diagnostic iteration, focuses extensively upon the correlation between symptom counts among DSM-III, DSM-III-R, and DSM-IV for somatization disorder rather than considering it as an unusual condition in its purest form. Furthermore, somatization disorder is rarely used by British psychiatrists, and the same could probably be said for United States colleagues.18 The low incidence of somatization disorder in the ECA studies may have been due to the use of lay interviewers, but it is an unusual syndrome in psychiatric settings, since such individuals often refuse to seek psychiatric treatment. Psychometrically, Rief and Hiller14 have noted a variety of problems for inventories that attempt to screen for somatization disorders: low base rates of certain somatic symptoms, minimal item-total correlations, and the question of discriminate validity of single symptoms. Sullivan19 has addressed the problems with the pain disorder category. Birket-Smith and Mortensen20 have also questioned the validity of pain disorder. In their recent study, major diagnostic overlap was demonstrated between somatoform pain disorder and conversion disorder, and very few significant differences were demonstrated in both axis I and II psychopathology. Independent of the major presenting complaint, the vast majority of their 127 patients had multiple pain as well as nonpain symptoms.20
An essential problem in somatoform disorder classification is that many of the categories exist as dimensions in clinical practice. The gradation of health anxiety to hypochondriasis depends upon a variety of factors, including the realistic health of the individual, his or her health-seeking behaviors, and degree of distress experienced. Costa and McCrae21 have demonstrated that somatic concerns correlate significantly with neuroticism. So are we trying to make categories out of concepts that are clearly dimensional?
Any new classification should not try to just change words but improve the section. The somatization disorders could be abridged to being either multisymptomatic or monosymptomatic by using some of Escobar's strategies.22–24 If pain is the primary complaint, it could be noted as a subclassifier of monosymptomatic somatoform disorder or as part of an adjustment disorder. Thus pain disorder could be discarded altogether.
Somatization is clearly a dimensional construct, and the work group should consider how to incorporate this into an axis II disorder. Tyrer et al.25 proposed "hypochondriacal personality disorder." Neurasthenia, which is an ICD-10 category, is omitted in the DSM iterations except as a passing text notation that it should be considered as an undifferentiated somatoform disorder. With the significant prevalence of fatigue states in the population,26,27 neurasthenia clearly needs more attention. Finally, the role of abnormal illness behavior could be discussed in the text, and various psychometric approaches, such as the Illness Behavior Questionnaire or the Research Criteria for Psychosomatic Disorders, could be included in an appendix to help the interested clinician.28,29
In conclusion, the somatoform disorders remain a difficult taxonomic challenge. They are primarily seen in primary care settings, have significant comorbidity with anxiety and depression, and are often dimensional in nature. Their classification is a complicated task that offers no easy solutions, but that is the reason why somatoform disorders clearly deserve a dedicated work group of their own with significant input from international experts.
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