Psychosomatics 47:277-281, August 2006
doi: 10.1176/appi.psy.47.4.277
© 2006 Academy of Psychosomatic Medicine
Somatoform Disorders and DSM-V: Conceptual and Political Issues in the Debate
Vladan Starcevic, M.D.
Received August 29, 2005; revised October 30, 2005; accepted November 10, 2005. From the Univ. of Sydney and Nepean Hospital. Address correspondence and reprint requests to Dr. Starcevic, Nepean Hospital, Dept. of Psychological Medicine, P.O. Box 63, Penrith NSW 2751, Australia. e-mail: starcev{at}wahs.nsw.gov.au
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ABSTRACT
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This article furthers the debate on the future of somatoform disorders by critically reviewing the relevant terminology and validity for the separate grouping and classification of these disorders. It is suggested that political pressures to change certain terms should be resisted, and that such changes should be made only if the alternatives have clear advantages.
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INTRODUCTION
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There appear to be sufficient reasons to group together the disorders mainly characterized by medically unexplained somatic symptoms, but it is still debated as to how these disorders are to be conceptualized, named, and classified. Because there is general dissatisfaction with the current conceptualization and classification of somatoform disorders, debate on the future of these conditions is much needed. Several editorials and lead articles on this topic have recently been published.1–6 The ideas for DSM-V range from a relatively "conservative" suggestion that changes should be made, while retaining the group of somatoform disorders,1,3,7,8 to a "radical" proposal to abolish the somatoform group altogether.2,4,9 There are many issues underlying these discussions, and it is possible to address only some of them here. Therefore, I will focus on the terminology and grouping of the disorders. In doing so, I will consider conceptual problems and political issues that appear to drive much of the debate.
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What’s in a Name?
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Experts in the field of somatoform disorders seem to disagree on almost every aspect of the relevant terminology. What name should we give to somatic symptoms unexplained by disease? What are we to call the disorders in which such symptoms are prominent? What should be the name for the whole group of conditions mainly characterized by these symptoms? Our conceptual and diagnostic labels matter a lot, considering what they reflect and imply and how they can be interpreted. Three criteria have been identified as particularly important in determining the suitability of terms in the area of somatoform disorders: patient acceptability, etiological neutrality, and compatibility with terminology used by nonpsychiatric physicians.2,4
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Patient Acceptability and Political Correctness
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The debate has largely revolved around the issue of what terminology might be acceptable to patients. It has been argued that the terms "somatoform symptoms" and "medically unexplained symptoms" are unacceptable to patients because the terms suggest that patients have a mental disorder, which indicates to them that the medical profession does not believe their physical suffering to be real or genuine.2,4,10 In contrast, other authors1,3 argue that these same terms offer a practical solution to the complex problem and that their meaning can be readily explained to patients and medical professionals, thereby minimizing the likelihood of misinterpretation. In the words of Wessely,11 "unexplained means what it says on the tin, and is not a code for ‘psychiatric,’ still less for ‘all in the mind’(p 95)."
The term "functional symptoms" has been proposed as a viable alternative to "medically unexplained symptoms."1,2,10 Apparently, the term "functional" is less offensive to patients than "medically unexplained."10 The term "subjective health complaints" was also considered advantageous because complaints are "real" phenomena for patients (as opposed to "symptoms") and because the term is deemed to be etiologically neutral.12 However, any term, even the most "neutral" or well-intentioned, can be misconstrued. For example, in one survey of newspaper articles,13 the term "psychosomatic" tended to be attributed a pejorative meaning or was often misinterpreted. There is no reason to believe that the term "functional symptoms" is free from the same propensity. Unless its meaning is well explained, "functional" may appear even more ambiguous than "medically unexplained." And, to the extent that ambiguity gives rise to misinterpretations, functional symptoms may also be interpreted as suggesting psychological causation and mental disorder. If so, it is far more important to explain what the terms mean than to emphasize how the terms may be misinterpreted. The preoccupation with misinterpretation potential could lead to an abolition of all but a few terms; it would probably see the disappearance of "psychosomatic" from the names of dozens of professional journals and societies.
Because of the pejorative and stigmatizing connotations often attached to the term "hypochondriasis," it was proposed to replace it with "health anxiety" and "health anxiety disorder."14,15 The justification for renaming hypochondriasis as health anxiety disorder was then sought in its links with anxiety disorders.2 The problem with "health anxiety disorder," however, is that this concept is not interchangeable with that of hypochondriasis: forms of hypochondriasis that are more related to depression, obsessive-compulsive disorder, personality disturbance, or other somatoform disorders would be left out if "health anxiety disorder" were to replace hypochondriasis in its conceptual entirety and be classified among the anxiety disorders.16,17 Certainly, the current diagnostic conceptualization of hypochondriasis is not satisfactory and needs to be revised; this revision should also clarify the range of psychopathology encompassed by hypochondriasis and formulate the corresponding diagnostic criteria. It would be erroneous if the revision efforts concentrate on substituting one term for the other.
I am concerned that this search for new and more "politically correct" terms would ultimately lead to the formation of neologisms. Thus, "valetudinarian" or "valetudin disorder" were suggested as alternatives to hypochondriasis.17,18 We would certainly be better off with terms that are acceptable to patients, but creating such terms is not always possible. A good example is "schizophrenia:" although the term is not popular with patients, there are no serious attempts to replace it with a more "patient-friendly" diagnosis. It is unrealistic to expect patients to "like" their own diagnoses: why should they like diagnoses of conditions that are responsible for so much of their suffering? By the same token, it seems unrealistic that we will ever be able to create diagnostic labels that have no potential of being misused and/or misinterpreted.
Perhaps there is too much concern that some terminology in the somatoform realm may be construed to mean psychological causation or close relationship with psychopathology. The inclusion of psychological components in various terms pertaining to somatoform disorders is not an offense, even if patients are not happy about it. I do not think we should be apologetic to patients about this. Their suffering, which is caused by somatic distress, is not trivialized nor misattributed by suggesting that psychological factors may help explain that suffering and/or that they may make suffering worse. To the contrary, a psychological perspective may improve understanding and add an empathic appreciation. When used with this meaning, the term "psychosomatic" does not seem inappropriate or offensive. Finally, we would not be doing a good service to our patients by concealing from them—through the use of a contrived or convoluted terminology—what we believe is a significant aspect of their clinical presentation.
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Etiological Neutrality and Conceptual Clarity
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In view of the generally poor understanding of the etiology of somatoform disorders, the relevant terminology should be etiologically neutral,2,4 or "atheoretical." Using that criterion, is the term "functional symptoms" more suitable than "medically unexplained symptoms?" Hardly so. The term "functional" refers to a presumed alteration in function, rather than structure.19—a pathophysiological disturbance, rather than a pathoanatomical change. However, a suggestion that functional change occurs without any structural alteration is highly speculative. Also, we do not really know that functional disturbances, as defined above, are causal in somatoform disorders. The term "medically unexplained symptoms" is not ideal because there is no precise stipulation as to what needs to be excluded for the term to be applied. But it suggests no etiological mechanism and is therefore more etiologically neutral; it really conveys our inability to account for symptoms as being a result of any known medical condition. The term was also considered suitable "because it brings honest ignorance to the fore (p 51)."20 Is it this acknowledgment of our lack of understanding, implicit in the term "medically unexplained symptoms" that is so unsettling?
From the perspective of etiological neutrality, it is curious that the proponents of radical changes2 did not suggest abandonment of the diagnostic label of conversion disorder. This is at odds with their view that "somatization" and "somatization disorder" are not adequate terms, because they are not etiologically neutral. If somatization means a "hypothetical process whereby mental illness manifests as somatic symptoms (p 850),"2 the same could be said of conversion. It would then be impossible to defend the name "conversion disorder" as etiologically neutral. A more descriptive and etiologically neutral term for conversion disorder could be a "pseudoneurological disorder." This term might not be popular with patients because of the prefix "pseudo," whereas a more "politically correct" term, such as "neurologiform disorder" would be cumbersome and artificial. Therefore, the more etiologically neutral and the more "patient-friendly" does not necessarily mean more suitable or more justifiable.
Conceptual clarity and consistency are important when using the terms "somatization," "somatoform," "conversion," "medically unexplained," "functional," and "psychosomatic." Each of these terms has advantages and disadvantages that should be acknowledged, rather than used mainly to favor one term over the other. Complete etiological neutrality is an illusion because our terms often reflect some ideas, hypotheses, or theories about etiology. Therefore, it is important to explain to patients (and others) that these terms are imperfect and that they do not necessarily suggest any particular etiology, even when they appear to do so.
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Compatibility With Terminology Used by Nonpsychiatric Physicians
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One of the most convincing reasons for changing current terminology comes from the lack of compatibility between psychiatric terms (e.g., "somatoform disorders") and terms currently outside the DSM system, which are used by nonpsychiatric physicians (e.g., "functional somatic syndromes"). Although the overlap between somatoform disorders and functional somatic syndromes is not complete, both groups include various psychosomatic presentations. It is confusing, for example, that irritable bowel syndrome might be classified as an undifferentiated somatoform disorder in DSM system: why should psychiatrists and gastroenterologists use two diagnostic labels for the same condition? This defeats the purpose of the diagnosis as a communication tool.
Before a common name for somatoform disorders and functional somatic syndromes can be adopted and diagnostic communication improved—for example, by calling them "psychosomatic distress syndromes"—a consensus must be reached between psychiatrists and other physicians as to what exactly is encompassed by these groups of disorders. What are the criteria for inclusion? What should find place in the new, "jointly-owned" group of disorders, and what should be left out? Are there several functional somatic syndromes or just one?11,21
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Do We Need "Somatoform Disorders"?
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Would the world be a better place with or without "somatoform disorders"? As expected, the views diverge on this issue. Whereas some4 predict that the "abolition of [the term] somatoform disorders would have a positive impact on both medicine and psychiatry (p 466)" and already speculate what it would be like to have "healthcare without somatoform disorders (p 466)" others3 caution that the "abolition of [the term] somatoform disorders would threaten both medicine and psychiatry (p 389)."
Perhaps the way to go is to ask some simple questions, rather than make far-reaching but highly hypothetical and seemingly biased predictions. For example, are disorders characterized by physical symptoms that cannot be explained by medical conditions a reality or a fiction? If we agree that they are real—and at least, there seems to be a consensus on that—should they form a separate group? If so, what should be included in the group? Finally, where should these disorders be classified?
The disorders in medicine and psychiatry are grouped together on the basis of some important and relatively specific characteristic that they share. For example, dysphoria would not serve this purpose well, because it is too broad a term, with mental disorders in different groups being characterized by various degrees of dysphoria. On the other hand, a significant mood disturbance as a predominant feature is considered sufficient to serve as a "unifying principle" for the grouping of mood disorders. The obvious question is whether the presence of medically unexplained physical symptoms as the main feature of the disorder is sufficient to place all such disorders under the same nosological umbrella. Some3 believe that it is; others2 disagree.
I argue that the presence of distressing medically unexplained physical symptoms as a key feature of somatoform disorders is sufficient as the basis for grouping them together because these symptoms are what patients present with; they are what patients seek help for; and they account for most of their functional impairment and disability. Accordingly, I believe that the group of somatoform disorders—whatever it might be called in DSM-V—should remain in the nosological system, as long as we have no medical explanation for patients’ symptoms.
The current group of somatoform disorders is too heterogeneous. For example, the term "body dysmorphic disorder" shares very little, if anything, with the other members of the group; it should be reclassified elsewhere, as has already been suggested.2,4,5 The case with hypochondriasis is more complex. It is also a heterogeneous concept:16 although hypochondriasis may appear as an independent diagnostic entity,22,23 some forms are conceptually closer to other somatoform,17 anxiety,24 and personality disorders.25 Overall, hypochondriasis may be characterized less by medically unexplained symptoms than by a dysfunctional style of appraising and experiencing health, illness, and physical symptoms, and by the corresponding abnormal illness behavior.
Because other somatoform disorders—somatization disorder, conversion disorder, pain disorder, and undifferentiated somatoform disorder—are primarily characterized by medically unexplained somatic symptoms, their placement within a group of somatoform disorders seems less controversial. Of course, there are unresolved issues and diagnostic dilemmas with each of these disorders, and they need to be conceptually refined.1,2,6,8 As indicated above, the group of somatoform disorders should also encompass some or all of the functional somatic syndromes (e.g., chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, noncardiac chest pain).
Where should somatoform disorders be classified? In other words, are these conditions primarily mental or primarily physical disorders? Does it really matter? Do such questions reflect our strong tendencies to endorse the mind–body dichotomy? At present, the classification of somatoform disorders exclusively among the mental disorders or exclusively among the physical conditions cannot be justified. Perhaps somatoform disorders could be placed in a new group or as a separate category,3 which would be located in the overlapping territory between the mental and physical disorders. It is a matter of further debate whether this new group or category is to be called somatoform disorders, functional somatic syndromes, or psychosomatic distress syndromes.
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CONCLUSION
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While considering changes for our current terminology in the area of somatoform disorders, we should bear in mind that we cannot construct terms that would be totally acceptable to patients and that would also be completely etiologically neutral. Patient acceptance and etiological neutrality are a matter of degree. Some terms may be more acceptable to patients, but less acceptable in terms of etiological neutrality, and vice versa. We need to resist political pressures to change certain terms, with such changes occurring only if the alternatives have clear advantages across all the criteria required to make the changes. In other words, solid conceptual, theoretical, and empirical reasons are needed to justify making changes in terminology. Rather than hurrying to discard the terminology that does not appear to be appropriate, we should make every effort to acknowledge the limitations of our current terms and to clarify them to patients and others.
The disorders mainly characterized by medically unexplained physical symptoms are real. Although I believe that the predominance of such symptoms is a sufficient basis for the grouping of these disorders, it is a matter of ongoing debate as to how the disorders are to be conceptualized, named, and classified. The collaboration between psychiatrists and nonpsychiatric physicians is crucial in this debate, with the ultimate goal being adoption of a system that would be uniform and acceptable to all.
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ABSTRACT
INTRODUCTION
