The Future of Somatoform Disorders
The Future of Somatoform Disorders
A major critique against the concept of somatoform disorders was the assumption that it strengthens mind–body dualism. It was suspected that 'somatoform' means somatic symptoms that are caused by psychological factors, although other somatic symptoms are caused by biomedical conditions, hereby splitting causes of diseases into biomedical versus psychological. However, DSM-III cannot be blamed for such an emphasis on psychological causes. DSM-IV requires that the somatic symptoms 'are not fully explained by a general medical condition' (p. 445), which is a typical wording of DSM, and appears in similar ways in other diagnoses as well (e.g. panic disorder). However, if a concept is frequently misinterpreted in several countries, this is usually hard to change, and therefore it should be seriously taken into consideration when revising a classification system.
Especially in those countries where somatoform disorders are a subject of stigmatization (e.g. due to the reasons mentioned above), the diagnosis was rarely used by the clinicians. A US-database including data of several hundred thousands of patients identified diagnoses of somatoform disorders with a neglectable low base rate. On the contrary, up to 20% of patients in primary care are supposed to suffer from somatoform disorders. If this diagnosis is not used for these patients, it is unclear which other diagnosis they receive, and this hinders any reasonable analysis of the relevance, treatment pathways and so on of this patient group. In line with this conflict, general practitioners seem to misdiagnose most patients with chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome (IBS).
The prototype of somatoform disorders, somatization disorder, was criticized to be over-restrictive, and to identify only a small, but highly disabled subgroup of patients with somatoform disorders. The few epidemiological studies that also assessed for somatoform disorders reported base rates lower than 0.1% for somatization disorder. On the contrary, medically unexplained somatic symptoms are a highly prevalent condition in the general population.
A further critique on the concept of somatoform disorders came from the notoriously low inter-rater reliability as to whether symptoms are medically caused. The distinction between medically explained versus medically unexplained somatic complaints requires a physician's rating on medical causality. However, although some GPs consider up to 30% of their patients suffering from medically unexplained symptoms, other physicians postulate that medically unexplained symptoms do not exist at all, but are underinvestigated medically caused symptoms and/or medically caused symptoms for which the medical causes will be found in the near future.
Finally, the concept of somatoform disorders was criticized because it remained unclear why somatic symptoms should be classified as a mental disorder at all. Most other diagnoses of DSM include some psychological features that characterize the syndrome, and therefore consider 'positive criteria' for the decision about the disorder. In contrast, somatization disorder and other somatoform disorders only require the presence of somatic symptoms that are not fully medically explained. The absence of a medical explanation itself does not justify classifying such a syndrome as a mental disorder. ICD-10, for example, has an own category on symptoms and signs that is different from psychiatric disorders (R category), and that is supposed to cover syndromes with unknown cause. If somatoform disorders should be classified as mental disorders, it was requested that somatoform disorders must include some psychological features that characterize these syndromes.
Whether the new proposals for the classification of medically unexplained symptoms fulfill all of these requirements is unclear. Therefore, we will highlight the unique advantages of some new proposals in the next section.
The Need for Revision of Somatoform Disorders
A major critique against the concept of somatoform disorders was the assumption that it strengthens mind–body dualism. It was suspected that 'somatoform' means somatic symptoms that are caused by psychological factors, although other somatic symptoms are caused by biomedical conditions, hereby splitting causes of diseases into biomedical versus psychological. However, DSM-III cannot be blamed for such an emphasis on psychological causes. DSM-IV requires that the somatic symptoms 'are not fully explained by a general medical condition' (p. 445), which is a typical wording of DSM, and appears in similar ways in other diagnoses as well (e.g. panic disorder). However, if a concept is frequently misinterpreted in several countries, this is usually hard to change, and therefore it should be seriously taken into consideration when revising a classification system.
Especially in those countries where somatoform disorders are a subject of stigmatization (e.g. due to the reasons mentioned above), the diagnosis was rarely used by the clinicians. A US-database including data of several hundred thousands of patients identified diagnoses of somatoform disorders with a neglectable low base rate. On the contrary, up to 20% of patients in primary care are supposed to suffer from somatoform disorders. If this diagnosis is not used for these patients, it is unclear which other diagnosis they receive, and this hinders any reasonable analysis of the relevance, treatment pathways and so on of this patient group. In line with this conflict, general practitioners seem to misdiagnose most patients with chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome (IBS).
The prototype of somatoform disorders, somatization disorder, was criticized to be over-restrictive, and to identify only a small, but highly disabled subgroup of patients with somatoform disorders. The few epidemiological studies that also assessed for somatoform disorders reported base rates lower than 0.1% for somatization disorder. On the contrary, medically unexplained somatic symptoms are a highly prevalent condition in the general population.
A further critique on the concept of somatoform disorders came from the notoriously low inter-rater reliability as to whether symptoms are medically caused. The distinction between medically explained versus medically unexplained somatic complaints requires a physician's rating on medical causality. However, although some GPs consider up to 30% of their patients suffering from medically unexplained symptoms, other physicians postulate that medically unexplained symptoms do not exist at all, but are underinvestigated medically caused symptoms and/or medically caused symptoms for which the medical causes will be found in the near future.
Finally, the concept of somatoform disorders was criticized because it remained unclear why somatic symptoms should be classified as a mental disorder at all. Most other diagnoses of DSM include some psychological features that characterize the syndrome, and therefore consider 'positive criteria' for the decision about the disorder. In contrast, somatization disorder and other somatoform disorders only require the presence of somatic symptoms that are not fully medically explained. The absence of a medical explanation itself does not justify classifying such a syndrome as a mental disorder. ICD-10, for example, has an own category on symptoms and signs that is different from psychiatric disorders (R category), and that is supposed to cover syndromes with unknown cause. If somatoform disorders should be classified as mental disorders, it was requested that somatoform disorders must include some psychological features that characterize these syndromes.
Whether the new proposals for the classification of medically unexplained symptoms fulfill all of these requirements is unclear. Therefore, we will highlight the unique advantages of some new proposals in the next section.
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