Psychosomatics 44:449-451, December 2003
© 2003 The Academy of Psychosomatic Medicine
Somatoform Disorders in DSM-V
Richard Mayou, M.D.,
James Levenson, M.D., and
Michael Sharpe, M.D.
From the Oxford University Department of Psychiatry, Warneford Hospital, Oxford, U.K.; the Division of Consultation-Liaison Psychiatry, Virginia Commonwealth University, Richmond, Va.; and the School of Molecular and Clinical Medicine, University of Edinburgh, Edinburgh, U.K. Address correspondence to Prof. Mayou, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom.
Several recent publications have prepared the way for an ambitious and extended program of research that will be the basis of DSM-V.1,2 In addition to the general organization of the classification, numerous fundamental issues of taxonomy are expected to be considered, including 1) the use of a more etiological approach; 2) the use of dimensions rather than categories; 3) changes in the definition of the threshold for a disorder; and 4) issues of reliability, validity, and utility.3 Inevitably, this process will have important consequences for consultation-liaison psychiatrists. We believe the main issue for us is the future of the somatoform disorders, since they refer to clinical problems that are increasingly the major focus of our clinical work, research, and teaching.4
The extended period of review and research proposed before the publication of even a draft for DSM-V is an opportunity for much more substantial change than could ever have been contemplated for DSM-III-R or DSM-IV. Since the whole of DSM (and also ICD) will be subjected to such review, this is an opportunity to improve the classification of conditions currently classified as somatoform disorders.
Somatoform disorders were included in DSM-III as a speculative category. Despite being subsequently extended and slightly modified, both the overall concept and the subcategories have continued to be much criticized, both by individuals and by DSM workgroups.5–8 While the text accompanying somatoform disorder has always included strong caveats about the difficulties in defining mental illness and about the tentative nature of the categories, this has not prevented research workers, health planners and funders, and others from attributing a much greater validity to these categories. Our clinical and academic expertise means that consultation-liaison psychiatrists are better placed than any other group of clinicians to be involved in this review; we believe it is essential that we assert this interest now and that we encourage and contribute to both the discussion and the provision of evidence.
Consultation-liaison psychiatrists share important clinical understandings of functional (i.e., somatized or unexplained) symptoms:
- They are very frequent in all medical settings. Although a sizable minority are chronic and disabling, few patients exhibiting these symptoms are referred to psychiatric services.
- They are often associated with well-established categories of psychiatric disorder, principally depression and anxiety. The term somatoform disorders is applied to other disabling problems in which psychological symptoms are less prominent.
- Psychological and behavioral understanding, and indeed treatment, may be appropriate whether or not a psychiatric diagnosis can be made.
- It is illogical and unsatisfactory that functional symptoms accompanying major physical disease are frequently not treated in the same manner as when they occur alone.
- There is also no clear reason why psychological reactions to functional symptoms are classified in a different manner to psychological reactions to physical disease.
In this context, consultation-liaison psychiatrists need to use psychiatric diagnoses constructively for their own purposes. At the same time, they are aware that medical and primary care colleagues will continue to use parallel taxonomy by symptom or descriptive syndrome terms (e.g., irritable bowel) and make little use of psychiatric terminology.9 We need to make our classification acceptable and helpful to patients wherever they are treated as well as to other doctors and to all those who use diagnostic labels in relation to health, social, and legal policies. It is apparent that our current terminology has not proved widely understandable and acceptable. In addition, there are fundamental major criticisms:
- The classification is an essentially dualist definition couched in terms of physical or psychological alternative etiologies. It has therefore proved particularly difficult in the many cultures that do not share the Western view of mind and body causes as alternatives.
- Diagnosing is inconsistent in that physical symptoms can be coded on both axis I and axis III.
- The more specific categories, such as hypochondriasis and body dysmorphic disorder, do not satisfy criteria for reliability, validity, or utility.
- Less specific categories that depend upon counting physical symptoms (somatization disorder, undifferentiated somatoform disorder) or the type of symptom (pain disorder) appear to be part of a continuum that lacks thresholds and are not associated with the psychological criteria one might expect in a psychiatric classification.
- The separation of dissociative and conversion disorder is arbitrary.
STATUS QUO, CHANGE, OR ABOLITION?
There are three possible ways in which DSM-V might respond to the criticism and dissatisfaction with the somatoform disorders category: 1) maintaining the status quo on the grounds that we still do not have compelling new evidence on which to base new classifications; 2) continuing the gradualist approach of DSM-III-R and DSM-IV as further evidence becomes available; and 3) promoting more profound changes in which the existence of the category and its subcategories are abolished in favor of an alternative scheme.
There is nothing to support the status quo. The view that the current grouping is convenient and politically valuable for consultation-liaison psychiatrists in giving recognition to conditions that might otherwise be lost is also consistent with the second, gradualist approach. Modifications accompanied by substantial changes in the text would be an important advance in understanding and a major contribution to dealing with misapplications and misinterpretation. This is the cautious approach already evident from reports of DSM-IV workgroups.5 Many of the suggestions considered by the DSM-IV workgroups and rejected as being too far-reaching for a relatively modest revision would be possible to explore for DSM-V. It would also be possible to consider changes in terminology and some relocation of existing categories within the classification. Major revision of the text, indicating a much more integrated view of etiology, would be a large advance.
More radical change would take greater account of the strength of the dissatisfaction with current categories and the ambitious overall agenda for DSM-V. Consultation-liaison psychiatrists might wish to consider the opportunities to move on from a classification that enables the neglect of somatic symptoms by psychiatrists and psychological aspects of medicine by physicians. It would require abolition of the somatoform disorders category and the reassignment and rethinking of subcategories.6 It would mean the transfer and renaming of several specific categories to other sections of the classification. For example, hypochondriasis might be included as health anxiety within the anxiety section.10 Body dysmorphic disorder might also be relocated to one or more other categories.11 Conversion should be reunited with dissociative disorder in its own grouping.
The greatest problems are the need to find a solution to the continuum of somatization disorder, undifferentiated somatoform disorder,12,13 and pain disorder,14 which are all defined in terms of number of physical symptoms. Although it is probable that these conditions are associated with abnormal patterns of perception, cognitive interpretation, and illness behavior, we still lack any substantial evidence for psychological criteria. One solution would be to classify the physical symptoms in terms of a severity dimension on axis III, alongside other physical conditions, plus an additional psychiatric diagnosis under psychological factors affecting medical condition or a personality disorder diagnosis as appropriate.
In considering these changes, it would be helpful if functional symptoms occurring alone could be classified in exactly the same manner as when they occur with major physical disease (for example, the common occurrence of noncardiac chest pain in those with proven ischemic heart disease). Much greater use of the category of psychological factors affecting medical condition would be an obvious way forward.
CONCLUSIONS
The DSM-V research agenda is ambitious and will embrace the whole of the present classification. The somatoform disorders section was introduced as being speculative, has been much criticized, and lacks a substantial evidence base. It has, however, become a major focus of consultation-liaison psychiatry. It refers to clinical problems in which there is an interaction of physiology, pathology, and psychological factors, factors for which consultation-liaison psychiatrists are arguably better placed to understand than any of their colleagues. We call for further research and debate about our basic concepts and terminology and also for active involvement in the political process that is the inevitable and fundamental part of revising a classification. We should at least contemplate the more radical solutions, such as abolition, even if in the end we opt for caution. At the same time, we need to much more effectively assert our clinical expertise. This should depend on saying and demonstrating what we can do rather than clinging to a terminology and classification that we ourselves know to be unsatisfactory, poorly understood by others, and unlikely to be acceptable to our patients.
We suggest that consultation-liaison psychiatrists should set out the ways in which the program for DSM-V might most usefully deal with a major developing area of their clinical expertise. Whether the outcome is major revision of the present category or abolition, this is an opportunity for fundamental discussion and further research. It is an opportunity to try and ensure that the issues that are not well understood within psychiatry, or in medicine as a whole, are given the attention they deserve. We hope that Psychosomatics will be a major forum for the debate.
REFERENCES
- Kupfer DJ, First MB, Regier DA: A Research Agenda for DSM-V. Washington, DC, American Psychiatric Publishing, 2002
- Phillips KA, First MB, Pincus HA (eds): Advancing DSM: Dilemmas in Psychiatric Diagnosis. Washington, DC, American Psychiatric Publishing, 2003
- Kendell R, Jablensky A: Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003; 160:4–12[Abstract/Free Full Text]
- Wise TN, Birket-Smith M: The somatoform disorders for DSM-V: the need for changes in process and content. Psychosomatics 2002; 43:437–440[Free Full Text]
- Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Davis WW (eds): DSM-IV Sourcebook, vol II. Washington, DC, American Psychiatric Publishing, 1996
- Phillips KA, Greenberg BD, Rasmussen SA: Should the DSM diagnostic groupings be changed? in Advancing DSM: Dilemmas in Psychiatric Diagnosis. Edited by Phillips KA, First MB, Pincus HA. Washington, DC, American Psychiatric Publishing, 2003
- De Gucht V, Fischler B: Somatization: a critical review of conceptual and methodological issues. Psychosomatics 2002; 43:1–9[Abstract/Free Full Text]
- Brugha TS: The end of the beginning: a requiem for the categorization of mental disorder. Psychol Med 2002; 32:1149–1154[CrossRef][Medline]
- Aaron LA, Buchwald D: A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 2001; 134:868–881[Abstract/Free Full Text]
- Noyes R Jr: The relationship of hypochondriasis to anxiety disorders. Gen Hosp Psychiatry 1999; 21:8–17[CrossRef][Medline]
- Phillips KA, Hollander E: Body dysmorphic disorder, in DSM-IV Sourcebook, vol II. Edited by Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Davis WW. Washington, DC, American Psychiatric Publishing, 1996, pp 949–960
- Dickinson WP, Dickinson LM, deGruy FV, Candib LM, Main DS, Libby AM, Rost K: The somatization in primary care study: a tale of three diagnoses. Gen Hosp Psychiatry 2003; 25:1–7[CrossRef][Medline]
- Kroenke K, Spitzer RL, deGruy FV III, Hahn SR, Linzer M, Williams JBW, Brody D, Davies M: Multisomatoform disorder: an alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997; 54:352–358[Abstract]
- Sullivan MD: DSM-IV pain disorder: a case against the diagnosis. Int Rev Psychiatry 2000; 12:91–98[CrossRef]
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