Introduction

The essential feature of somatization disorder is that the patient presents multiple, medically unexplained symptoms, i.e. physical complaints suggesting a physical disease that cannot be adequately explained on the basis of organic pathology or any known pathophysiological mechanism.

The diagnosis has its origin in the concept of hysteria. (i2.) It was introduced in DSM-III in 1980 and was based on the criteria for 'Briquet's syndrome', a syndrome described in the early 1960s by Perley and Guze.(3) They listed 59 physical and psychological symptoms distributed in 10 groups: 25 of the symptoms from nine groups were required to qualify for the diagnosis of somatization disorder. All psychological symptoms were eliminated in the DSM-III modification to avoid overlapping with other diagnoses.

The diagnostic criteria for DSM somatization disorder varied until the introduction of the current DSM-IV. The diagnosis was included in ICD-10 (4) in 1992, but the ICD-10 criteria list different symptoms and require a different number of symptoms compared with the corresponding DSM criteria.

The somatization disorder diagnosis has been criticized for being too rigid for clinical use. Only the most severe cases with a specific predefined symptom profile will fulfil the diagnostic criteria, and the majority of those with multiple symptoms fall into one or other of the residual categories of 'Undifferentiated' or 'Not otherwise specified' somatoform disorder/5»

To increase the sensitivity, Escobar et al.(6) introduced an abridged somatization index. This required four symptoms for males and six symptoms for females out of the 37 somatic symptoms listed in the DSM-III, compared with 12 and 14 symptoms respectively for the full DSM-III somatization disorder diagnosis. Kroenke et al.(D have suggested a diagnosis of 'multisomatoform disorder', defined as three or more medically unexplained physical symptoms from a 15-symptom checklist along with at least a 2-year history of medically unexplained symptoms.

However, these abridged versions share the same basic problem as the original—that no single physical symptom or sign is specific for somatization disorder and related disorders, and that the chosen number of symptoms to qualify for the individual diagnosis will always be arbitrary. (1,8,9)

The phenomena of medically unexplained symptoms cannot simply be classified into one or a few diagnostic categories, but must be regarded as the expression of a basic mechanism by which people may respond to stressors as in the cases of depression and anxiety. (819 Somatization disorder and related disorders must thus be considered to possess a spectrum of severity. In this chapter the focus will be on the chronic and multisymptomatic forms.

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