Somatoform disorders

Somatoform disorders (Tabie.3) were seen as provisional in DSM-III and this remains true of both DSM-IV and ICD, but unfortunately both classifications have been interpreted as suggesting much greater validity than actually intended. The defining feature is 'physical symptoms suggesting a physical disorder for which there are no demonstrable organic findings on known physiological mechanisms, and for which there is strong evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts'. There are a number of problems in the overall concept of somatoform disorders.

Table 3 Categories of somatoform disorders in ICD-10 and DSM-IV

• There is a lack of any clear operational definitions for the overall category.

• Some types of somatoform disorder (especially severe hypochondriasis and somatization disorder) are so enduring that they might more appropriately be classified as personality disorder.(9)

• Criteria have little meaning for cultures that do not share the Western presumption of the separation of body and mind.

• Many subjects whose symptoms satisfy criteria for somatoform disorders also report psychological symptoms of anxiety or depressive disorders. Comorbidity, with two psychiatric diagnoses, is very common for this whole group of patients.(2)

There are substantial differences between ICD and DSM in the subcategories, and comparisons have found little agreement between them. Neurasthenia is included in ICD-10 but is not used in any section of DSM-IV; conversion disorder is a somatoform disorder in DSM-IV but not in ICD. Both classifications include several relatively specific categories (e.g. somatization disorder and hypochondriasis) and several very vaguely defined non-specific categories. These include undifferentiated somatoform disorder, somatoform autonomic dysfunction (ICD-10 only), and other somatoform disorders. Although the latter have attracted less clinical and research attention, they are by far the most common forms of somatoform disorder in all epidemiological studies. So broad and vague are the criteria that it is possible to use these categories for almost all persistent unexplained physical symptoms. Comparisons of ICD and DSM suggest substantially different prevalences in community and primary care populations for somatoform disorders as a whole.

The more specific categories lack reliable and valid definitions. The clinical descriptions are largely derived from hospital-based experience and are not readily applicable to the large number of people with unexplained symptoms in the community and primary care settings. Further problems are that diagnostic criteria are based on a mixture of principles—aetiology, symptom count, consultation, and response to medical treatment.

The problems encountered in people with somatoform disorders in Western countries, which are described above, together with the lack of any useful meaning for cultures that do not accept the mind-body separation that underlies their definition, means that great caution is necessary when using this category. It is important to recall that somatoform disorder remains a provisional grouping for statistical purposes rather than a grouping of categories that satisfy the normal requirements of disease entities. At present, we lack the knowledge for major revision in this section and there seems little advantage in making minor changes to laboriously developed schemas. It is more realistic to encourage a critical view of the somatoform categories, whilst accumulating evidence for practical classifications for use in everyday practice by both specialists and non-specialists.

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