Current debates over nosology of somatoform disorders.

There is a wide debate among the researchers and clinicians over the diagnostic categories subsumed under the rubric of somatoform disorders (SDs). Recent proposals vary from radical views that call for removing this category altogether to the conservative views that suggests cosmetic changes in the diagnostic criteria of SDs. We have the reviewed the relevant literature through PUBMED search supplemented with manual search on current concepts of SD.

Somatoform disorders (SDs) are often thought to be residing in the no-man's land between the territories of medicine and psychiatry overlooking the fact that they are the essential keystone to maintain the integrity of the two disciplines. The symptoms have taken many names over the years. Clinicians and researchers have proposed a wide range of theories for their etiology, diagnosis or treatment. However, reaching a consensus has been almost an impossible proposition. Their ideas and concepts have been just as varied as the unexplained symptoms themselves. So, controversy regarding their diagnosis has been a rule rather than exception. Therefore, we reviewed the existing literature through PUBMED search supplemented with manual search on current concepts of SD.

DIAGNOSIS AND ITS EVOLUTION OVER THE YEARS

Historical Antecedents to modern classification

It was Briquet who first studied a syndrome characterized by multiple somatic symptoms and named it ‘hysteria’, Stekel defined it as a bodily disorder arising as the expression of a deep-seated neurosis.[1] Lipowski's definition: “The tendency to experience, conceptualize, and/or communicate psychological states or contents as bodily sensations, functional changes or somatic metaphors” was even more lucid.[2] However, this definition was questioned for its emphasis over ‘psychological distress’ rather than the ‘somatic distress’ which is primarily experienced and communicated by these patients.[3] So this was later revised to: “A tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness and to seek medical help for them.”[3] This revised definition is considered the basic framework on which the concept of hysteria has evolved over the years.

The evolution of nosology of hypochondriasis was through a different process. Sydenham in 17th century described it as a ‘disturbance and inconsistency of both mind and body’ and as the male counterpart of hysteria.[3] Through the 18th century, hypochondriasis was considered a part of a ‘fashionable disturbance’ that Cheyne attributed to the ‘English way’ of life and environment till Falret in 1822, identified it as a mental disorder. Subsequently Gillespie, in 1928 defined it as: “A mental preoccupation with a real or supposititious physical or mental disorder”; a definition which passed the test of time.[4]

Conversion disorder has its roots in the classical psychoanalysis school. Breuer and Freud proposed that mental distress might be converted into physical dysfunction symbolic of that distress. Subsequently the term “conversion” symptoms emerged essentially denoting those functional neurological disturbances.[5] In their initial observation both Charcot and Janet acknowledged involvement of body and mind in hysteria. However, Janet later emphasized that conversion was solely mental in origin, thereby dismissing the role of physical lesion hypothesized by Charcot.[6] Freud's views have been reflected in International Classification of Diseases (ICD)-10 as well as in Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV both underscoring the role of unconscious motives and emotional conflict in generating hysteria, with a split in mental processes between the symptom and the underlying conflict.[7]

Morselli, more than a century ago, first described body dysmorphic disorder (BDD).[8] Janet's description of a young woman who for 5 years confined herself in her apartment, worrying that she would never be loved for being ‘ugly and ridiculous’, was the next instance in psychiatric literature. It was initially classified as the atypical SD dysmorphophobia in DSM-III before the current name came up in the next edition.[89]

The concept of neurasthenia was defined by the neurologist Beard in 1869 who described it as “a disease of nervous system, without organic lesion, which may attack any or all parts of the nervous system, and characterized by enfeeblement of the nervous force, which may have all degrees of severity”.[10] Its first appearance in DSM-II resulted from the attempt to increase congruency with ICD-8.[1112] However the western world saw its declining relevance and it was finally dropped out from DSM-III; though ICD has been retaining it till date, as a subtype of neurosis.[13]

Modern classificatory system

DSM-III derived the concept of somatization disorder from the criteria for ‘Briquet's syndrome’, as described and operationalized by Perley and Guze.[14] Divided among 10 groups a total of 59 physical as well as psychological symptoms were enlisted among which 25 symptoms from nine groups were required to qualify for the diagnosis of somatization disorder. Later in an attempt to avoid overlapping with other diagnoses, all psychological symptoms were eliminated in the DSM-III modification.[15] This change which essentially delineated the psychological dimension from the physical had drawn criticism. Oken opined that the “over reliance on the old biomedical model, rather than the biopsychosocial model by DSM-III downplayed the benefits achieved by its dynamic framework comprising the psychological, biological, and social factors.”[1617]

DSM-IV field trial

The wide variance in prevalence of SD–Epidemiological Catchment Area study showing 0.2-0.3% by Robins, et al. compared with 2% by Woodruff, et al. using different diagnostic criteria made the ground for DSM-IV field trial which aimed to settle these discrepancies in criteria.[1819] The prevalence of somatization disorder was assessed using a semi-structured interview instrument, specifically designed for the field trial.[20] DSM-III-R and DSM-IV criteria showed good agreement in the final result but none of them matched with ICD-10 criteria.[2122] According to the authors that was because of the inherent lack of concordance of ICD-10 with other criteria.[2023]

Current nosology: A comparison of DSM-IV and ICD-10

Compared with DSM-III, DSM-IV adopted a simpler approach, requiring a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms for the diagnosis of somatization disorder.[22] Undifferentiated SD denotes an array of unexplained physical symptoms which do not cross the threshold for somatization disorder. SD Not Otherwise Specified is kept as a residual category. BDD has been added and the definition of Conversion Disorder has been modified. DSM-IV defines Conversion Disorder as symptoms affecting voluntary motor and sensory functions in contrast to the DSM-III definition of any symptom suggestive of a physical disorder.[22] The criteria for Pain Disorder are modified to include subtypes: (1) Associated With Psychological Factors; (2) Associated With Both Psychological Factors and a General Medical Condition; and (3) With a General Medical Condition alone.[22]

Several changes in the criteria for hypochondriasis have also been made. DSM-IV states that the belief is not delusional, is not secondary to anxiety, depression or other SD and the minimum duration has to be 6 months.[22] Moreover, the “Psychological Factors Affecting Medical condition” has been substituted by “…Physical” condition. This subcategory is broken down into several types: Mental disorders…, psychological symptoms…, personality disorders or traits…, and stress responses… affecting medical conditions; and maladaptive health behaviors.[22] Separate criteria for Specific Phobia, Other Type (illness) are introduced. The fear of contracting a serious illness is characteristic of patients with illness-phobia, contrary to the patients with hypochondriasis who believe that such illness already exists.[22]

The ICD-10 Diagnostic Criteria for Research (DCR) criteria differ from those in DSM-IV in several important respects. It has reduced the symptom threshold for somatization disorder by including ‘multiple and variable unexplained symptoms representing at least two organ systems’ and increased the duration criteria to at least 2 years.[23] BDD has been incorporated in the criteria for hypochondriasis.[23] It has included a category called Somatoform Autonomic Disorder characterized by symptoms of autonomic arousal in the absence of any disturbance of structure or function.[23] Also, the ICD-10 criteria for Pain Disorder require persistent, severe, and distressing pain (continuously for at least 6 months; in contrast to DSM-IV where duration is not mentioned) that cannot be explained by a physical condition, omitting the mention of ‘psychological factors’ categorically specified in DSM-IV.[23] Conversion disorder (conversion hysteria) has been renamed and reclassified as a dissociative rather than SD.[23] Further, neurasthenia has been included in ICD-10 but is not used in any section of DSM-IV.[2223]

CURRENT CONTROVERSIES

Limitations of current nosology

It has been argued that the current nosology violates etiological neutrality assuming the cause of the symptoms in SD to be essentially psychological. This ‘Psychogenic causation’ and the pejorative terms e.g., “poor historians”, “doctor shopping” is unacceptable to many patients.[24] It also makes the current nosology unacceptable in many cultures that do not share the western view of mind and body causes as alternatives.[25] The current Chinese classification, for example, is based on DSM but specifically excludes the SD category.[26] In India also, the traditional view of diseases and disorders never assumes mind body dualism.

Diagnosing is inconsistent as physical symptoms can be coded on both Axis I and Axis III. Moreover, the labeling of somatic symptoms as SD often leads to under diagnosis of anxiety or depression, especially in countries like ours where somatization is often an expression of depression.[2427] On the other hand, the lower-threshold undifferentiated SD is variably applied and has a hierarchical rule precluding its diagnosis if the symptoms are better accounted for by a depressive and anxiety disorder, which is practically often ambiguous.[28]

SDs present as a rare condition and it does not relate to the more widely used general medical classification of functional somatic syndromes (such as irritable bowel syndrome) that are used in primary care.[24] Population-based studies (e.g., Fink, et al.) contradicted the existing criteria for SD (by both DSM-IV and ICD-10) as the syndrome found there did not quite match with the symptoms described in the diagnostic system.[29] Leiknes, et al. have shown that SD has a poor stability over time and among its subtypes there is substantial overlap.[30] These evidences taken together do question the validity of the current diagnostic system which has been highlighted by Löwe, et al.[31]

Mayou, et al. argue that the thresholds set for various disorders are either too low (e.g., Pain Disorder) or too high (e.g., SD).[32] Less specific categories that depend upon counting physical symptoms (SD, undifferentiated SD) 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.[32]

From medico-legal perspective Mayou, et al. argue that the current nosology validates spurious diagnosis for simple symptom complaints, but doubts the authenticity of somatic symptoms as “merely psychiatric.”[32] The value of somatoform diagnoses in guiding treatment is limited and often taken simply to indicate a need to minimize access to medical care.[33]

Strengths of current nosology

Levenson states that the compromise of etiological neutrality has come against delineating the relative contribution from psyche and soma, which is essential in understanding the condition.[34] This problem with etiology is similar in major depression with severe heart failure, where the relative contributions of fatigue, insomnia, and anorexia are always vague but one should try to find it out in order to plan a successful treatment.[34]

Hiller and Rief argue that introduction of the SDs in 1980 (DSM-III) has stimulated research and new clinical developments much stronger than any traditional concept in the pre-DSM-III decades.[35] Changing the names or giving up the concepts (as suggested by Mayou, et al.) would ignore the large progress made in the field in diagnosis and treatment.[32]

Starcevic, criticizing the appeal to change names, says that this search for new and more “politically correct” terms would ultimately lead to the formation of neologisms.[36] He reminds that patient acceptability is not necessarily related to the term we use to define the condition, e.g., “schizophrenia” – the term is unpopular because the condition is dreaded and not because of any literal flaw in the term itself.[36] It is said that unacceptability of the terms to patient can be easily overcome by ready explanations to patients and medical professionals. In the words of Wessely and White, “unexplained means what it says on the tin, and is not a code for ‘psychiatric,’ still less for ‘all in the mind’.”[37] Starcevic emphasizes that a psychological perspective may improve understanding and add an empathic appreciation to SD.[36] He adds that the inclusion of psychological components in various terms pertaining to SDs is not an offense, even if patients are not happy about it.[36]

DSM-IV (and DSM-III before that) provides a straightforward way of handling unexplained somatic symptoms that are the focus of psychological or psychiatric attention, namely, to diagnose Psychological Factor Affecting a Medical Condition (316) on Axis I and to diagnose the symptom(s) on Axis III.[34] If treatment expertise is considered the main issue, then the classification of SDs on Axis I is justified, as most suggestions for effective treatments came from psychosocial medicine.[38] Similarly shift of this category to Axis III should be considered with caution as most patients with other mental disorders (e.g., panic disorder) also seek treatment in general practitioners rather than mental health professionals.[39] Hiller says SD is essentially a mental disorder and not a somatic disease as the altered perception, cognition and illness behavior (e.g., somatosensory amplification) play central role in this condition despite a poorly understood organic pathology.[40] He says that a description of symptom level cannot replace a diagnosis as they are from different diagnostic levels.[40] The presence of symptoms does not necessarily imply that the person also fulfills the criteria of a diagnosis. Diagnostic categories, therefore, are indispensable.

PROPOSED RECOMMENDATIONS FOR FUTURE NOSOLOGY

The controversies in defining SD paved way for some alternate terminologies and criteria. Included among these newer alternatives were multi-SD, abridged SD, body distress disorder, polysymptomatic SD, medically unexplained symptom spectrum disorder, and physical symptom disorder, among others.[2941-45] The changes made in those criteria were: Lowering the threshold for diagnosis, regrouping the somatic symptoms or suggesting about a common underlying factor beneath the array of symptoms. However, suggestions for a new approach in classification of SD in the upcoming DSM-V or ICD-11 have come up of late.

Different views have been proposed ranging from radical to more conservative views: (1) “Radical views” to eliminate SD from psychiatry (Axis I) and add SD only in Axis III or in U category of ICD; (2) “Less radical views” include broader conceptualization of SD, alternate definitions of individual disorders and addition of new categories of sub-threshold conditions.

RADICAL VIEWS

Should we eliminate somatoform disorder category?

Oken says, all diseases, and health, are psychosomatic; there are no “psychosomatic disorders” because there are no non-psychosomatic ones.[16] Another group of researchers consider SD heterogeneous since the grouping is based on clinical considerations (i.e., the need to exclude physical conditions), rather than on similarities between individual disorders and shared mechanisms.[32] A reassignment of conditions has been suggested by them, e.g., Conversion Disorder can be moved to dissociative disorder section; Hypochondriasis might be relocated to the anxiety disorders (health-anxiety disorder) or placed within an obsessive-compulsive spectrum.[32] BDD can also be included in that spectrum.[32] Thus the entire Somatoform category gets eliminated. Yet another proposition has been to reclassify Somatization Disorder among the unstable (Cluster B) personality disorders.[5]

Should somatoform disorders be regarded as psychiatric disorders?

As SDs are relevant to all medical disciplines and indeed more frequently seen by general physicians than by psychiatrists, it has been argued that they should be placed in a completely new category (e.g., “section U”) in ICD-10 instead of under the F-category of psychiatric disorders.[46] An innovative approach by modifying the existing classification to add new axes for behavioral, emotional, and cognitive variables was proposed by Rief and Sharpe.[46]

BROADER CONCEPTUALIZATION OF SOMATOFORM DISORDERS

Biological processes are increasingly being implicated behind the causation of SD with evidences of role of immunological abnormalities and also preliminary results from the use of functional brain imaging to assess cerebral and peripheral processes contributing to the development of physical symptoms.[47-49] So on top of the cognitive and behavioral characters, psychophysiological and psychobiological correlates of SD needs consideration. The communication between patients and doctors is inadequate in the current medically-biased health care system which has a tendency to invalidate patients’ complains.[50] Therefore, adding cross-cultural perspectives into it would ensure a better understanding than what the dualist approach can provide. Various propositions are discussed below.

Diagnostic Criteria for Psychosomatic Research (DCPR) Criteria: These authors proposed to change this category into “psychological factors affecting either identified or feared medical conditions” with clinical specifiers as sub-classification headings.[51] They argued that by expanding medical conditions to both “identified” and “feared,” clinical specifications can be regardless of the functional/organic dichotomy or Axis I or II comorbidity.[51] Disease phobia, ‘a highly prevalent variant of hypochondriasis’ has been added to the list. Persistent somatization, conceptualized as a clustering of functional symptoms involving different organ systems would replace somatization disorder and undifferentiated SD.[51] Finally, DCPR categories of illness denial, demoralization, and irritable mood are mentioned as further specifiers.[51]

Influenced by the conceptualization of SD as personality disturbances, interpersonal model, stress diathesis model, Noyes, et al. have proposed a reconceptualization of SD as interpersonal disturbance in DSM-V.[552-55] The basic framework proposed by them includes five criteria:[5]

Marked and persistent distress related to, and preoccupation with, physical symptoms, illness, defect, or impairment. The formulation for grouping must begin with somatic distress

Marked and persistent illness behavior related to physical symptoms, illness, defect, or impairment. Focus should be on care eliciting behaviors (reassurance seeking, sick role privileges, medical care, etc.) as they would guide ultimate health care

The somatic distress and illness behavior cause impairment in physical, occupational, or interpersonal functioning. As with any other disorder areas of dysfunction caused by the disorder has to be highlighted

The disturbance is chronic

The distress is not better accounted for by other psychiatric disorders.

Conceptual Issues in Somatoform and Similar Disorders (CISSD) Recommendations: One of the primary recommendations is to make somatization disorder a more inclusive one by either ‘broadening the definition’ or by including lower threshold categories along with the existing one.[45] CISSD also recommends deleting undifferentiated SD, to move pain disorders to Axis III and to code them as dual diagnosis with simultaneous coding in Axis I as well if psychological factors are also present.[45] An alternative terminology of “Health Anxiety Disorder” has been suggested in place of Hypochondriasis. For Conversion Disorder and BDD the suggestions have been either to create separate categories under SD or to move them to Dissociative Disorders and Obsessive-Compulsive Disorder, respectively.[45] Besides, moving mono-syndromic/symptomatic conditions to Axis III, omission of pejorative language (e.g., “Doctor-shopping”) and to make DSM-V and ICD-11 more compatible are the other recommendations.[45]

Fava, et al. suggests that seven diagnostic categorizations (hypochondriasis, disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood) should be added to the current general definition of psychological factors affecting medical conditions in DSM-V.[56] Hypochondriasis and Disease Phobia 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 SDs, with the exception of BDD, which can be placed among the anxiety disorders. Somatic symptoms and syndromes would fit in Axis III of DSM.[56]

CONCLUSION

The modern diagnostic systems which are said to have established the triumph of nominalism over naturalism have struggled to find even a suitable name for SD. Current controversy regarding the diagnosis of SD in the upcoming DSM-V and ICD-11 is between a radicalist and a conservative approach. Accordingly, from total abolishment of the category to lowering of threshold for inclusion of less severe but more common versions with necessary regroupings of subcategories, there have been a wide range of recommendations. A review is warranted in the organization, terminology, and criteria of the SD in both DSM-IV and ICD-10. However, one must remember that our primary goal is to improve care for patients with somatic symptoms in clinical settings in different levels of health care. In a country like India where prejudices and superstitions often preclude proper consultation with the right person at the right time, it seems that the major changes required are in the health care delivery systems and in the attitudes of health care providers, well ahead of any change in nosology.