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Psychosomatics 48:103-111, April 2007
doi: 10.1176/appi.psy.48.2.103
© 2007 Academy of Psychosomatic Medicine
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Review

Psychological Factors Affecting Medical Condition: A New Proposal for DSM-V

Giovanni A. Fava, M.D., Stefania Fabbri, Psy.D., Laura Sirri, Psy.D., and Thomas N. Wise, M.D.

From The Dept. of Psychology, Univ. of Bologna, Bologna, Italy. Send correspondence and reprint requests to G.A. Fava, M.D., Dept. of Psychology, Univ. of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. e-mail: giovanniandrea.fava{at}unibo.it


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 DISCUSSION
 REFERENCES
 
The DSM category of "psychological factors affecting medical condition" had virtually no impact on clinical practice. However, several clinically relevant psychosomatic syndromes have been described in the literature: disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood. These syndromes, in addition to the DSM definition of hypochondriasis, can yield clinical specification in the category of "psychological factors affecting medical condition" and eliminate the need for the highly criticized DSM classification of somatoform disorders. This new classification is supported by a growing body of research evidence and is in line with psychosomatic medicine as a recognized subspecialty.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
DISCUSSION
 REFERENCES
 
Since its introduction in DSM-III, the classification of somatoform disorders has attracted considerable criticism. Because the section is organized by the common feature of physical symptoms that suggest a general-medical disorder, it may lead the clinician to the false choice of deciding in a dichotomous manner whether the symptoms are based on an underlying medical condition or are due to the use of somatic terms as a proxy for psychosocial problems.1–5 Lipowski explained somatization as the tendency to experience and communicate psychological distress in the form of physical symptoms and to seek medical help for them but never ruled out the concurrence of an organic process.1 It is not surprising that many questions have arisen regarding this term. In particular, the DSM classification has performed poorly in primary-care and clinical samples, excluding a substantial proportion of patients displaying psychological distress and functional somatic symptoms.1–5 The DSM-IV workgroup for somatoform disorders also focused on dissociative, impulse control, and adjustment disorders. Many international investigators whose careers have focused on somatoform disorders were not part of the workgroup.

Recently, Mayou et al.6 proposed that DSM-V abolish the diagnostic category of somatoform disorders and redistribute some of its current diagnoses into other groupings. Hypochondriasis should be renamed "health anxiety disorder" and grouped with body-dysmorphic disorder within anxiety disturbances. Somatization disorder would be defined as a combination of personality disorder (Axis II) and mood or anxiety disorders (Axis I). Somatic symptoms and syndromes and pain disorder would be classified on Axis III for reporting current general-medical conditions. Dissociative and conversion symptoms would remain separate.6

In response to these suggestions, Hiller and Rief7 and Noyes et al.8 acknowledged that the classification of somatoform disorders lacks support in many areas and requires substantial modifications. However, they suggested that the diagnoses of hypochondriasis and somatization disorders have traditionally been recognized and are clinically distinct forms of somatic distress, each with prognostic and therapeutic implications.7,8 Other suggestions for classifications of somatization have come from Fink et al.,9 who elaborated a staging system for patients presenting with functional somatic symptoms in primary care, and Kroenke,10 who has proposed the new diagnostic category of Physical Symptom Disorder on Axis III, to replace somatization disorder, undifferentiated somatoform disorder, and pain disorder.

All these proposals and alternatives need to be tested and validated against DSM criteria. In this article, we formulate a new proposal that has the advantage of being supported by a growing body of research evidence. It is based on the already-existing DSM category of psychological factors affecting medical condition; it is now found in a section devoted to "conditions that may be a focus of clinical attention" and is not part of the somatoform section. The essential features of the diagnosis are the presence of a general-medical condition and psychological factors adversely affecting its course and treatment or constituting health risks and stress-related physiological responses. The problem with this category was that it was too vague and lacked clinical specificity about the characteristics of these factors based on the available psychosomatic research.11 Indeed, it virtually had no impact on clinical practice.

Our proposal is to designate "Psychological Factors Affecting Medical Conditions" as a new section of DSM that consists of the syndromes described below. We propose expanding this category with reliable qualifiers to better describe the elements of the psychological factors. The clinical specifiers consist of one DSM-IV somatoform diagnosis (hypochondriasis) and six syndromes that derive from the Diagnostic Criteria for Psychosomatic Research (DCPR) and the concept of abnormal illness-behavior. The DCPR were developed by an international group of investigators12 and were found to be more suitable than DSM-IV criteria in identifying distress and impaired quality of life in medically ill populations.13–24

Disease Phobia and Illness Denial expand the spectrum of illness behavior; in DCPR, Persistent Somatization and Conversion Symptoms are redefined to replace DSM diagnoses of Somatization Disorder, Undifferentiated Somatoform Disorder, and Conversion; the descriptions of demoralization and irritable mood offer operational definitions to subclinical syndromes that can frequently be encountered in the medical setting.11

Some psychosocial clusters are also based on Pilowsky’s concept of abnormal illness-behavior, characterized as the persistence of a maladaptive mode of perceiving, experiencing, evaluating, and responding to one’s health status, despite the fact that a doctor has provided a lucid and accurate appraisal of the situation and the management to be followed, if any. The maladaptive mode persists even though the patient has been provided with opportunities for discussion, negotiation, and clarification, based on adequate assessment of all relevant biological, psychological, social, and cultural factors.25 Hypochondriasis and Disease Phobia pertain to the illness-affirming expressions, whereas Illness Denial pertains to the illness-denying modalities.

We will describe the seven clinical qualifiers that we suggest for expanding the category of "psychological factors affecting medical condition," and we will discuss the implications of this approach for medical practice.

Hypochondriasis
The DSM-IV classification of Hypochondriasis underlines three main aspects of the disease:

  1. A cognitive component: the misinterpretation of bodily symptoms, physical signs, or sensations, leading to the preoccupation with and the belief in having an illness;
  2. An affective element: the fear of having a disease;
  3. A behavioral change that leads to distress or impairment in social, occupational, or other important areas of functioning, and reassurance-seeking.

When hypochondriasis is secondary to another psychiatric disorder, such as depression or anxiety, the treatment of the primary condition leads to the reduction of hypocondriacal fears and beliefs.27–29 On the other hand, when hypochondriasis presents itself as a primary condition, it is directly amenable to treatment. Several randomized, controlled trials have highlighted the fact that various treatment packages for hypochondriasis, mainly incorporating cognitive-behavioral techniques, have been found to be effective.30–36

Most treatment packages share some nonspecific treatment factors, such as therapist attention, arousal, disclosure, interpretation, ritual, a thorough preliminary medical and physical examination in order to exclude any physical condition responsible for health preoccupations, education about the most common causes of bodily sensations, and, finally, the monitoring of bodily sensations, thoughts, and emotions.27 More specific treatment factors consist of cognitive restructuring in cognitive therapy; exposure and response-prevention in behavioral treatment; reassurance that the patient does not have a physical illness, in explanatory therapy; and relaxation, assertiveness training, and stimulus-control exercises for reducing worry in behavioral stress-management.37

Untreated hypochondriasis is associated with considerable invalidism and impaired quality of life, and it is unlikely to remit spontaneously.38 Hypochondriacal fears and beliefs may also be present with physical disease, such as peptic ulcer and lung disease. False beliefs about the disease make it more difficult to cope with the disease, induce anxiety and depression, and can lead to a preoccupation with symptoms.27 The distinction of hypochondriasis as a discrete category thus rests on a solid foundation,8 unlike the definition of health anxiety. When is health anxiety justified? After breast cancer or a myocardial infarction, does the absence of anxiety lead to poor follow-up or the rejection of lifestyle changes such as smoking cessation?

Disease Phobia
The DCPR criteria12 conceptualize disease phobia as follows: 1) a persistent, unfounded fear of suffering from a specific disease (e.g., AIDS, cancer), with doubts remaining despite adequate examination and reassurance; 2) the fear tends to manifest itself in attacks, rather than in constant, chronic worries, as in hypochondriasis; panic attacks may therefore be an associated feature; 3) the object of fear does not change with time, and duration of symptoms exceeds 6 months. Disease phobia is not included in DSM-IV.

Fava and Grandi39 underlined two main clinical features of disease phobia. The first is the specificity and longitudinal stability of the symptoms (e.g., patients who fear having cancer are unlikely to transfer their fear to another disease—AIDS, for example), whereas hypochondriacal patients are likely to switch the object of fear over time. The second characteristic of disease phobia is the phobic quality of the fears,40 which tend to manifest themselves in attacks, rather than in constant, chronic worries, as in hypochondriasis.

These two main differences between hypochondriasis and disease phobia lead to different therapeutic approaches. Warwick and Marks41 successfully used exposure to illness cues with 17 subjects suffering from disease phobia. The phobic quality of the fear, typical of disease phobia, often leads to an avoidance that can be faced with in-vivo exposure. On the other hand, the constant fear of diseases that is characteristic of hypochondriacal patients often leads to "doctor-shopping" behaviors that may render exposure ineffective. In this sense, the relationship of disease phobia to hypochondriasis is similar to the one of panic disorder and generalized anxiety. Furthermore, unlike hypochondriasis, disease phobia was found to respond to imipramine.42 These differences suggest two separate categories, rather than a definition of disease phobia as a subtype of hypochondriasis.

Illness Denial
The DCPR criteria for Illness Denial are outlined in Table 1. DCPR criteria for Illness Denial identified this phenomenon in several clinical contexts, with a prevalence ranging from 2% in dermatological inpatients24 to 29% in consultation–liaison psychiatry patients.18


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TABLE 1. Criteria for Illness Denial (both A and B are required)



In the conceptual framework of abnormal illness-behavior,25 illness denial represents a psychological response to one’s own illness and covers several phenomenological phenomena ranging from an unrealistic optimism to complete denial of disease. According to the broad spectrum of illness-related features that can be denied, distorted, or minimized, many components of illness denial have been identified.43 For instance, patients can deny urgency, seriousness, affect, personal relevance, responsibility, long-term prognosis (including the possibility of death), implications of the diagnosis, and the need for therapy or treatment.43

Denial of physical illness has been described in a variety of clinical settings, especially in patients with cancer and diabetes, as well as renal, cardiovascular, and neurological disorders.18,43–47 Much has been debated about the adaptive/maladaptive role of illness denial.43 In the early stages of life-threatening diseases, after diagnosis, as well as in the terminal phase, a certain degree of denial alleviates psychological distress, and, in women with non-metastatic breast cancer, this denial may be associated with longer survival.46

Denial is considered maladaptive when it prevents the adoption of healthy behaviors, results in a delay in seeking medical care, and causes nonadherence to therapies or lifestyle modification programs.48 In these cases, denial may worsen the course of disease, as was found to occur in patients with diabetes, where it was associated with hematologic markers of poor metabolic control.45 Non-acceptance of illness may be displayed as counterphobic behavior; this is the case of the patient with hemophilia who engages in risky behaviors. In healthy subjects, illness denial may represent a risk factor for unsafe health habits, as was found for HIV/AIDS-related risk denial.49

Despite its clinical relevance, maladaptive illness denial has been neglected as a psychiatric classification.50 Some authors have proposed the inclusion of denial in DSM-IV as a subtype of adjustment disorder.50

Persistent Somatization
Kellner2 summarized some characteristics of patients suffering from various functional medical disorders, such as non-ulcer dyspepsia, urethral syndrome, and irritable bowel syndrome. He also suggested that it may be advantageous to conceptualize a somatizing patient as someone whose psychophysiological symptoms have clustered. His work is the basis of the DCPR criteria outlined in Table 2. Similar DSM constructs involve somatization disorder and undifferentiated somatoform disorder. However, the former is rarely found,4 and the latter lacks any clinical information, aside from the presence of somatic symptoms, which could be listed on Axis III.


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TABLE 2. Criteria for Persistent Somatization (both A and B are required)



Recently, various studies in different medical settings have used DCPR in order to assess the frequency and characteristics of persistent somatization. The prevalence of the syndrome in endocrine patients was 21%,20 and, in a group of subjects experiencing their first episode of myocardial infarction, was 14%.47 In a sample of 190 subjects suffering from functional gastrointestinal disorders,13 the percentage of patients meeting the criteria for persistent somatization reached as much as 38%. In this study, in more than two out of three cases, persistent somatization was not associated with DSM somatoform disorders; therefore somatization phenomena that would otherwise have been missed could be detected. Only in a few cases, the DSM category "Undifferentiated Somatoform Disorders" detected disturbances that could not be subsumed under the rubric of persistent somatization. This phenomenon can be explained by the fact that, despite the criteria for persistent somatization being more selective than those used to define undifferentiated somatoform disorder, the former could also be diagnosed in the presence of a comorbid psychiatric or medical condition. Interestingly, DCPR "persistent somatization" seldom occurred in a community sample,51 which is in striking contrast with the prevalence of functional somatic symptoms in general populations.4

Conversion Symptoms
According to DSM-IV, the differentiation between somatization disorder and conversion is mainly based on the number of symptoms, rather than more precise clinical features. Stone et al.,52 in a review article, highlighted the fact that a misdiagnosis of conversion symptoms was reported in early studies, but this rate reached a level of only 4% in studies after 1970. The authors explained this decline "...as probably due to improvements in study quality rather than improved diagnostic accuracy...," pointing out how the difficulties in making a diagnosis of conversion disorder are still present.

Table 3 outlines the diagnostic criteria for conversion symptoms on the basis of Engel’s stringent criteria,53 which are incorporated in DCPR. Symptoms or deficits affecting voluntary motor or sensory functioning that are not explained by organic causes are often labeled as "conversion symptoms." Porcelli et al.13 found that 5% of subjects suffering from functional gastrointestinal disorders present with DCPR conversion symptoms, and Ottolini et al.,47 in a population of subjects with their first episode of myocardial infarction, found conversion symptoms in 7% of the patients. This confirms previous findings on the occurrence of conversion symptoms in the setting of life-threatening medical illness.54


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TABLE 3. Criteria for Conversion Symptoms (A through C are required)



Demoralization
According to Frank and Frank,55 demoralization represents a common reason for subjects’ seeking psychotherapeutic treatment. It results from awareness of being unable to cope with a pressing problem or of having failed to meet one’s own expectations or those of others.

Several definitions of demoralization have been proposed, ranging from "a normal response to adversity"56 and " a nonspecific psychological distress"57 to a specific syndrome resulting from the convergence of distress and subjective incompetence.58

Schmale and Engel59 identified a psychological state, the so-called "Giving Up/Given Up Syndrome," that clearly describes the distinctive features of demoralization, which is characterized by feelings of helplessness, hopelessness, subjective incompetence, and a loss of mastery and control. This syndrome was found to occur frequently before the onset of medical disorders and can be exacerbated or triggered by a physical illness, especially if life-threatening or disabling, or by painful and prolonged treatments, such as chemotherapy and mastectomy.56

Hopelessness, the most relevant feature of demoralization, independently from depression, was associated with suicidal intent and action both in medical and psychiatric patients60 and seemed to increase the risk and worsen the prognosis of cardiovascular diseases and cancer.59–61

Despite its clinical and prognostic relevance, demoralization has not been adequately recognized by traditional psychiatric classifications, and can only be inferred by DSM-IV criteria for adjustment disorders.

The application of the DCPR operational criteria (Table 4) has allowed us to document the occurrence of demoralization across different medical settings, substantiating previous findings that used dimensional tools.62 Demoralization was found to be one of the most frequent syndromes in medically ill patients, with a prevalence of almost 30%.13,14,18,20,22–24 Even though there was a considerable overlap with the diagnosis of major depressive disorder, 44% of depressed patients were not demoralized, and 69% of demoralized patients were not depressed.23 In cardiology, its presence as a prodromal symptom of cardiac events has been outlined.47 This syndrome seemed to be far less frequent among subjects recruited in a community sample.51 These findings suggested that demoralization and major depression are overlapping, yet constitute distinct clinical phenomena, not hierarchically linked: patients can be demoralized but not depressed, and vice versa.


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TABLE 4. Criteria for Demoralization (A through C are required)



Some authors have suggested that demoralization in medically ill patients may be reduced by a regular, supportive, and emphatic relationship between the patient and the healthcare providers.56,60 Specific psychotherapeutic interventions, based on cognitive and behavioral or interpersonal techniques, may also be potentially helpful.63 Future studies should clarify whether relief from demoralization results in a better illness course and outcome. Demoralization is not simply an adjustment disorder. It may be the most common disorder in consultation psychiatry.55

Irritable Mood
The most clinically relevant features of irritability have been well described by Snaith and Taylor64 in the following definition "a feeling state characterized by reduced control over temper, which usually results in irascible verbal or behavioral outbursts, although the mood may be present without observed manifestation. It may be experienced as brief episodes in particular circumstances, or it may be prolonged and generalized. The experience of irritability is always unpleasant for the individual, and overt manifestation lacks the cathartic effect of justified outbursts of anger."

Several phenomena related to irritable mood have been differentiated: inward and outward irritability, hostility, aggression, and anger are similar but distinct phenomena. Irritable mood can represent a different mood state, independent of other anxious or depressive disorders;64 yet irritability may be secondary to all the major psychiatric disturbances and Type A behavior.65

There are various pathways linking irritability and physical illness.65 Irritability can be induced by physical illness, as is frequently observed in endocrine disorders,20 and may represent a psychological response to hospitalization, disability, pain, treatments, and diagnostic procedures, as seen in prenatal examination. Irritability and other, related, mood states also seem to be involved in the development of physical illnesses.65,66

Several findings have substantiated a relationship between hostility, in particular, its cynical component, and an increased risk of cardiovascular diseases such as hypertension, atherosclerosis, atrial fibrillation, coronary heart disease, and myocardial infarction, especially in younger subjects.23,61,66–68 Hostile cynicism can often be subsumed, however, under the rubric of irritable mood. Unexpressed anger has been addressed as a predisposing factor to cancer,61 chronic pain, and functional somatic symptoms.27 Increased levels of irritability have been observed both in organic65 and functional gastrointestinal disorders;69 anger, in particular, seems to influence colon activity, and trait-anger reactivity predicts its severity.69 Furthermore, hostility and irritability were found to be significant predictors of unhealthy behaviors such as smoking and excessive alcohol consumption.66

Table 5 outlines the DCPR criteria for irritable mood. In a sample of 609 outpatients recruited from medical settings, DCPR Irritable Mood was identified in 27% of patients, and major depression was present in 19% of patients.70 Even though there was considerable overlap between the two diagnoses, 67% of the patients with major depression were not classified as irritable, and 77% of the patients with irritable mood did not satisfy the criteria for major depression.70


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TABLE 5. Criteria for Irritable Mood (A through C are required)



An important line of research is concerned with treatment of irritable mood and whether such treatment accrues beneficial effects on the associated medical illness. Because irritable mood is one symptom found in a variety of disorders, such as major mood disorder, it could be utilized as a subclassifier in major mood disorder,71 to indicate, for instance, a greater likelihood of vascular morbidity.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 DISCUSSION
REFERENCES
 
In the early sixties, David Kissen72 stressed the importance of asking who the patients are, within a given illness population, for whom psychosocial variables are of primary significance, instead of asking which psychological factors give rise to which illness.

The developments of psychosomatic medicine in the subsequent four decades11 have supported his view. Psychosomatic investigators have attempted to demonstrate that a certain psychological characteristic ("X") is more prevalent in Condition "A" than in Condition "B." Even when they found significant differences by use of reliable statistical and psychometric methods, this did not mean that every patient with "A" also presented with "X," and that a patient with "B" might not have presented with "X" features. Not surprisingly, replication attempts have often been disappointing, as one would expect from the characteristics of modest sensitivity and low specificity in heterogeneous medical entities.11

The development of specific criteria for the DSM category of Psychological Factors Affecting Medical Condition follows Kissen’s strategy72 of translating psychological characteristics observed in various medical settings into diagnostic criteria, which may enhance clinical (prognostic and therapeutic) value, and may be studied across disorders. These criteria would also fulfill Halliday’s wish, expressed 60 years ago,73 of acquiring phenomenological aids that may allow identification of psychosomatic distress across different somatic disorders (whether of functional or organic nature). By using these categories in the field of functional medical disorders, psychosomatic specialists may bring together a large number of seemingly unrelated disorders whose names have been scattered so widely under the headings of various anatomical systems,73 and may pave the way for multidisciplinary work in clinical medicine.74

We suggest that the seven diagnostic categorizations we have discussed (hypochondriasis, disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood) be added to the current general definition of psychological factors affecting medical conditions in DSM-V. The inclusion of Hypochondriasis and Disease Phobia is appropriate, given that they are accompanied by medical symptoms and syndromes and may be independently associated with physical disorder. They should be used in conjunction with all other Axis I and Axis II diagnoses; this would eliminate the need for diagnoses now subsumed under the rubric of Somatoform Disorders, with the exception of Body Dysmorphic Disorder, which can be placed among the anxiety disorders. Somatic symptoms and syndromes can find room in Axis III of DSM. The advantage of this classification is that it departs from the organic/functional dichotomy of medical disturbances and from the misleading and dangerous assumption that if organic factors cannot be identified, there should be psychiatric reasons that may be fully able to explain the somatic symptomatology.

Psychosomatic literature provides an endless series of examples of investigations where psychological factors could only account for part of unexplained medical disorders.11 Similarly, the presence of a nonfunctional medical disorder does not exclude, but indeed increases, the likelihood of psychological distress and abnormal illness-behavior.54 All these subcategories of psychological factors affecting medical condition should be seen as tentative; they may change or be discarded as soon as new data become available. Our proposal, unlike other suggestions, is supported by a growing body of research and may offer solution to the inadequacies of the current classification of somatoform disorders, without losing or misplacing the clinical syndromes that inspired it. Furthermore, it is in line with a large body of psychosomatics research using dimensional tools and with psychosomatic medicine as a recognized subspecialty. Finally, it is more in keeping with a unified concept of health and disease75–79 and the psychosocial needs of medical patients.


  ACKNOWLEDGMENTS

 
This work was supported in part by a grant from the Ministero dell’Università e della Ricerca Scientifica e Tecnologica (MURST; Roma, Italy) to Dr Fava.

We thank the Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY; the Division of Medical Psychology, Department of Psychiatric Medicine, University of Virginia, Charlottesville, VA; and the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD.

Dr. Wise is on the speakers’ bureau of Lilly, Pfizer Inc., U.S. Pharmaceuticals Group, and Glaxo Smith-Kline, and is on the advisory board of Lilly. He is also Editor-in-Chief of Psychosomatics.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 DISCUSSION
 REFERENCES
 

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