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Somatic Symptom Disorders: a new approach in DSM-5
J. E. Dimsdale
University of California, San Diego, DSM Task force, Somatic Symptoms Work Group, E-Mail: [email protected]
Keywords
Summary
Psychiatric diagnosis,
psychosomatic medicine,
somatoform, DSM-5
Following a brief historic discourse, problems with the current use and concepts the of somatoform disorders are described. The rationale for substituting the term „somatoform“
with „somatic symptom“ in DSM5 is explained and the new classification criteria for the
group of “somatic symptom related disorders” are described, which include severity ratings.
A special aspect is that “Illness anxiety disorder” is introduced as a new diagnostic entity in
DSM-5.
Schlüsselwörter
Zusammenfassung
Psychiatrische Diagnose,
Psychosomatische Medizin, somatoform, DSM-5
Nach einem kurzen historischen Diskurs werden die Problembereiche und die Konzepte der
somatoformen Störungen erläutert. Das Rational für einen Ersatz der „somatoformen“ Störung durch eine „Störung mit somatischen Symptomen“ in DSM5 wird erläutert. Die Klassifikationskriterien der Gruppe der „Störungen mit somatischen Symptomen“ wird dargestellt. Ein besonderer Aspekt ist die Einführung einer „Erkrankungsangst-Störung“ in
DSM-5.
„Störung mit somatischen Symptomen“: ein neuer Ansatz in DSM-5
Die Psychiatrie 2013; 10: 30–32
Received: 01. January 2013
Accepted after revision: 16. January 2013
P
sychosomatic illnesses are responsible for an enormous amount of distress and impairment. In addition,
the costs for diagnosis and treatment of these various disorders are substantial.
Historically, they occupied a pivotal position in the earliest DSM but have increasingly been defined as less central in the English-speaking psychiatric countries. In the
initial DSM published in 1952 (1) psychosomatic disorders
were called “Psychophysiologic autonomic disorders and
visceral disorders.” They constituted one of 8 chapters in
the book. In comparison, in DSM-IVTR, the psychosomatic
disorders have been fractionated and distributed across
various sections of the book and are given minimal attention; somatoform disorders occupy <40 pages out of an
943 page volume (2). On the other hand, in many countries psychosomatic medicine has been emphasized. There
are for instance hundreds of psychosomatic hospitals in
Germany and Switzerland.
The causes for the American de-emphasis of psychosomatic medicine are complex. Somatic issues share considerable “territory” with depression and anxiety. The de-
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velopment of improved treatments for depression and
anxiety has led to tremendous advances in these areas as
well as additional research on their epidemiology, clinical
trials, etc. There has also been a sea change in weltanschauung in psychiatry. From 1930–1970 psychoanalytic
perspectives defined the field, and much of psychosomatic
medicine was aligned with these perspectives. With the
decline in emphasis of psychoanalysis and the simultaneous growth of excellent research and non-psychoanalytic treatment options, psychosomatic medicine has been
over-shadowed.
“Over-shadowed” may not be the correct word for it.
Psychosomatic issues have not gone way. It’s not that they
were flawed diagnoses akin to theories about phlogiston.
It’s not that they have gone away because, like polio, the
illness has all but vanished. Instead, the challenge of diagnosing and treating these patients has reverted to primary
care doctors and certain specialists such as neurologists.
So, how satisfied are doctors with the current diagnoses
in psychosomatic medicine? One way of examining this is
to scrutinize coding of diagnoses in insurance registries.
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Theme Article
We know that psychosomatic illnesses are very common.
Are the diagnoses being used? Levenson (3) examined a
large cohort of over 28 million insurance holders and
found that these diagnostic codes were simply not being
used. For instance somatization disorder and undifferentiated somatoform disorder were coded on insurance forms
with a frequency of 0.0000199 out of ~28 million individuals. We conducted focus groups of doctors in the United
States and Great Britain and then followed up by polling
psychiatrists and internists in the United State, Canada,
and Great Britain (4). We learned that doctors regard the
status quo diagnoses as untenable for two reasons.
The central problem with the conceptualization of somatoform disorders in DSM-IV is that they define the core
difficulty as medically unexplained symptoms (MUS). This
problematic premise fosters a mind-body dualism. The reliability of diagnosis of MUS is notoriously limited. It
bases a diagnosis on what is NOT there as opposed to positive features that are detected on examination. Patients
don’t like the concept that “it is all in your head.” Doctors
are reluctant to use these diagnoses, as they are regarded
as stigmatizing.
A second problem with somatoform disorders is that
there is a profusion of diagnoses that are untenable and
duplicative. Doctors find the term “somatoform” confusing in and of itself. Furthermore, doctors report substantial
overlap amongst these disorders. Some of the disorders
seem unnecessarily detailed. For instance, factitious disorder had 2 variants depending upon whether the presentation was primarily falsely focused on psychological
symptoms or physical symptoms. False is false! What is
gained by adding this level of complexity to a diagnostic
inventory? It would be as if we have a different coding for
whether a paranoid schizophrenic is delusional about the
CIA vs the FBI or the Stasi!
In short, the somatic symptoms workgroup learned that
the status quo was deeply flawed. It was regarded as demeaning to patients. It was regarded as baroque in its
complexity, and it was deeply confusing. In response,
DSM-5 has done away with the older terminology of ‘somatoform’ in favor of a simpler descriptor “somatic symptom disorders.” It has gathered the various somatic symptom disorders into one chapter in the book in the hopes
that this will facilitate comparison and contrast, as well as
differential diagnosis. Table 1 lists the disorders that will
be included in this section.
DSM-5 acknowledges that disorders frequently are distributed on a continuum rather than categorically. Certainly, “hypertension” exists, but blood pressure is distributed continuously, and it is somewhat arbitrary to assign cut points for a diagnosis of hypertension. In DSM-5,
there are severity indicators, typically on 3-point scales,
that help clinicians rate the severity of each disorder. Such
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severity ratings may also help government or private insurance companies determine resource allocation. Thus,
although the historical categorical diagnostic approach is
retained, it is supplemented with guidance to demonstrate
the severity of the disorder.
The somatic symptoms workgroup sharply reduced the
number of diagnoses, either by elimination or by regrouping. For factitious disorder, the variants were reduced from
2 to 1. For psychological factors affected medical condition (PFAMC), the 6 subtypes were entirely eliminated in
favor of one diagnosis. They weren’t being used and were
not regarded as helpful. Somatization disorder, undifferentiated somatoform disorder, hypochondriasis and the 3
variants of pain disorder were regrouped into Somatic
Symptom Disorder and Illness Anxiety Disorder.
Somatic Symptom Disorder is defined by persistent somatic symptoms that are deeply distressing and impairing
as well as disproportionate thoughts, feelings, and behaviors regarding these symptoms. There is no challenge to
the authenticity of the patient’s symptoms; all suffering is
authentic. The somatic symptoms may or may not be
medically explained. The point is that the patient’s life is
catastrophically dominated by the symptoms in a way that
pervades his or her thoughts, feelings, and behaviors. Because somatic symptoms are common and vary greatly in
terms of their significance and import, guidance on severity indicators is provided.
The diagnosis of Illness Anxiety Disorder was introduced
in recognition of the fact that a minority of hypochondriacs, about 20%, has tremendous health concerns even in
the absence of somatic symptoms. Instead, these patients
are worried that they might get sick or else that they have
some undiagnosed malady even though they lack symptoms. The remaining 80% of hypochondriacs are grouped
within the diagnosis of Somatic Symptom Disorder.
The changes in Conversion Disorder are less radical but
still substantial. First off, in recognition of practice patterns particularly in Europe, DSM-5 introduces a parenthetical with the diagnosis. Thus, conversion disorder becomes “conversion disorder (functional neurological
Table 1 Somatic Symptom Related Disorders. The major psychiatric
diagnoses in Somatic Symptom Related Disorders are listed on the
left. On the right are the DSM-5 and ICD-numbers.
Somatic Symptom Disorder
300.82 (F45.1)
Illness Anxiety Disorder
300.7 (F45.21)
Conversion Disorder
(Functional Neurological Symptom Disorder)
300.11 (F44.4-F44.7)
Psychological Factors Affecting Other Medical
Conditions
316 (F54)
Factitious Disorder
300.19 (F68.10)
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Theme Article
symptoms disorder).” It is hoped that this will facilitate
better understanding among non-psychiatrists. The second
and more substantial change to conversion is the clarification that the neurological symptoms are not just medically
unexplained. Rather, they must be medically incompatible
with known pathophysiology.
There are some minor text edits to PFAMC and Factitious disorders, but the fundamental characterization of
these disorders remains similar to DSM-IV.
What are the challenges? All classification schemes are
to a certain extent arbitrary. DSM-5 has tried to provide a
classification scheme that is simpler to use and logically
based on similar diagnostic principles. Hopefully, this will
be a step forward. We subjected the most radically new diagnosis – Somatic Symptom Disorder – to formal reliability testing and it performed well (5). Not only was there
good reliability across multiple time points and evaluations, but also there was good agreement between doctor
and patient as to the severity of their disorders. Clearly, it
will be important to conduct further reliability studies in
the future, but such studies are best performed after clini-
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cians have been taught how to use this categorization.
Thus, one of the vital next steps is to develop educational
material to teach physicians and other health care practitioners how the new diagnoses are conceptualized and
recognized. Careful delineation of the epidemiology of
these disorders is necessary in planning treatment and in
assessing such treatment.
References
1. Committee on Nomenclature and Statistics. American Psychiatric
Association, Diagnostic and Statistical Manual Mental Disorders,
Washington, D.C. 1952.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fourth Edition Text Revision, Arlington,
Va, 2000.
3. Levenson J, The somatoform disorders: Six characters in search of
an author, Psychiatric Clinics of North America 34: 515–524.
4. Dimsdale J, Sharma N, Sharpe M. What do physicians think of somatoform disorders. Psychosomatics 2011; 52: 154–159.
5. Regier D, Narrow W, Clarke D, Kraemer H, Kuramoto S, Kuhl E,
Kupfer D. DSM-5 Field Trials in the United States and Canada, Part
II: Test-Retest Reliability of Selected Categorical Diagnoses. Am J
Psychiatry, October, 2012.
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For personal or educational use only. No other uses without permission. All rights reserved.