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 Table of Contents  
DEBATE/PERSPECTIVE/VIEWPOINT
Year : 2018  |  Volume : 34  |  Issue : 5  |  Page : 29-33

Nosological journey of somatoform disorders: From briquet's syndrome to bodily distress disorder


1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication20-Nov-2018

Correspondence Address:
Dr. Santosh K Chaturvedi
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_37_18

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  Abstract 


Classification of bodily, physical, or somatic symptoms has been a challenge since the classificatory systems have been introduced. The names/labels have undergone a change from hysteria to bodily distress disorder to remove the pejorative terms. The diagnostic criteria have also been modified as there have been significant criticisms of the utility of the categories included under somatoform disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and International Classification of Disease, Eleventh Edition have addressed some of the concerns that were raised in the previous version of the classifications by renaming the categories and simplifying the diagnostic criteria to improve clinical utility of the diagnostic categories.

Keywords: Bodily distress disorders, Diagnostic and Statistical Manual of Mental Disorders, Eleventh Edition, Fifth Edition, International Classification of Disease, nosology, somatic symptom, somatoform disorders


How to cite this article:
Desai G, Sagar R, Chaturvedi SK. Nosological journey of somatoform disorders: From briquet's syndrome to bodily distress disorder. Indian J Soc Psychiatry 2018;34, Suppl S1:29-33

How to cite this URL:
Desai G, Sagar R, Chaturvedi SK. Nosological journey of somatoform disorders: From briquet's syndrome to bodily distress disorder. Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Dec 11];34, Suppl S1:29-33. Available from: http://www.indjsp.org/text.asp?2018/34/5/29/245832




  Introduction Top


The classification of patients with bodily symptoms who come for psychiatric assessment and management is difficult to diagnose and manage. Somatic or bodily symptoms are common across health settings. The underlying reason for the symptoms could be a medical illness and psychiatric conditions such as anxiety or depression in which autonomic and somatic symptoms are quite common or unexplained. Medically unexplained somatic symptoms are considered part of somatoform disorders. They are characterized by multiple physical symptoms without any organic or medical basis for the symptoms. The symptoms are associated with significant help-seeking and impaired functioning. Classification of somatoform disorders has undergone significant change over a period of time. This article focuses on the evolution of the diagnosis and the classification of somatoform disorders in the popular classificatory systems and the validity and utility of the diagnosis and classification. However, the utility and validity of the proposed criteria in International Classification of Disease, Eleventh Edition (ICD-11) will be evident only once they are used clinically in the future.


  Evolution of the Diagnosis Top


The term hysteria was historically used to describe phenomena related to dissociation, somatization, and conversion. The three conditions were understood to have shared phenomenology. The earliest descriptions were attributed to spirit possession and a “wandering uterus” or a “proteus” or an “emotional condition rather than as a physical disorder and the source was shifted from the uterus to the central nervous system.”[1]

“Hysteria” was described as a chronic disorder with multiple medically unexplained symptoms in different organ systems by Briquet. Symptoms such as amnesia, paralysis, anesthesia, pain, spasms, and convulsive fits were included in the study.[2]

Sydenham's description of hysteria, revived by Savill, was one which is “manifested by an immense variety of nervous, neuromuscular, neurovascular, sensory, and other symptoms which may be referable to almost any organ or part of the body.”[3] Feighner criteria (St. Louis Criteria) attested the above description of hysteria but renamed it as “Briquet's syndrome.” Briquet's syndrome included a history of at least 25 symptoms which were clinically significant and medically unexplained from an overall list of 59 symptoms, occurring in at least 9 of 10 organ systems, beginning before the age of 30 years.[4]

Lipowski introduced the term somatization and defined it as “the tendency to experience, conceptualize, and/or communicate psychological states or contents as bodily sensations, functional changes, or somatic metaphors.” This description was criticized for highlighting the psychological distress rather than somatic distress which is experienced by patients. Later, the description of somatization was 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.” This definition is considered as a basic framework for further developments in classification of somatoform disorders.[5],[6],[7]


  Diagnostic and Statistical Manual of Mental Disorders and Somatoform Disorders Top


Diagnostic and Statistical Manual of Mental Disorders, First Edition (DSM-I) and DSM-II did not mention somatoform disorders.[8],[9] In DSM III, the St. Louis criteria for Briquet's syndrome were added. To make a diagnosis of somatization disorder in DSM-III, there needed to be at least of 14 of 37 possible symptoms without specific requirements of distribution of symptoms throughout multiple organ systems. Conversion disorder, psychogenic pain disorder, hypochondriasis, and atypical somatoform disorder were also included in the somatoform disorders category. Psychoform symptoms (term used to characterize psychological symptoms of Briquet's syndrome) from the Perley-Guze criteria for Briquet's syndrome were not included in DSM-III criteria for somatization disorder.[10] Conversion disorders were grouped with somatoform disorders and dissociative disorders were excluded.[11]

The DSM-III-R made some alterations to the description of somatoform disorders and included somatoform pain disorder and body dysmorphic disorder. In DSM-IV and DSM-IV-TR, somatization disorder needed only 8 out of the 32 symptoms. The name of somatoform pain disorder was changed to pain disorder.[12]

In the DSM-5, somatoform disorders have been put into a new section termed “somatic symptom and related disorders.” For somatic symptom disorder (SSD), a diagnosis requires one or more physical symptoms that cause distress or significant disruption of daily life. The requirement that the symptoms be medically unexplained has not been included in SSD criteria. Diagnoses of hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been excluded. There is no requirement that the symptom(s) must be associated with psychological conflicts or stressors. Factitious disorder section has been removed, and these disorders have been moved into the section for somatic symptom and related disorders.[13] The criteria require a duration of 6 months with a “persistent” specifier if the symptoms are for more than 6 months. A specifier for the severity of SSD as mild, moderate, or severe based on the number of symptoms present has been added.

In DSM-5, the diagnosis of hypochondriasis has been replaced by SSD and illness anxiety disorder (IAD). Both diagnoses have high health anxiety as a common criterion, but additional somatic symptoms are only required for SSD but not IAD.

There have been several criticisms of the DSM-5 SSD category. Diagnostic inflation and inadequate field testing have been reported to be the major criticisms.[14] There is a high chance of misdiagnosing a medical illness, including chronic pain conditions, as a mental illness.[14],[15],[16] Patients with medically unexplained symptoms, medical patients with emotional distress, patients with typical chronic pain conditions, and patients with health-related anxiety would qualify for SSD resulting in high variability.[16],[17],[18]

The field testing of DSM-5 has reported a high reliability coefficient; however, it was considered to be “not meaningful” as the data on validity of SSD are lacking. The field testing did not include primary care settings and sample size was inadequate.[19],[20] Other drawbacks of the DSM-5 SSD diagnostic category may be stigma, missed diagnoses owing to a failure to investigate new or worsening somatic symptoms, increased risk of receiving inappropriate psychotropic medications, and increased risk of women receiving the diagnosis.[21] A field trial in mental health clinical practice settings reported that the DSM-5 approach to diagnosis was feasible.[22]

Despite the criticisms, the changes that have been considered positive include the removal of criteria for the presence of a psychological stressor and the need for a number of symptoms. The presence of psychological stressor for making a diagnosis would be indicative for a causality and might be absent in patients and subject to recall bias. A number of symptoms that have been used in the previous diagnostic symptoms were arbitrary and not subject to research-based evidence. A single symptom which is severe in intensity can lead to significant dysfunction. The removal of these criteria makes the diagnosis easier to use in clinical settings as identifying psychological factors can be a challenge.


  International Classification of Disease and Somatoform Disorders Top


The ICD started as a list of causes of death but the sixth edition started including diseases and injuries. The ICD-6 mentioned psychoneuroses with somatic symptoms and psychoneuroses without anxiety which included hysteria. This was later modified to psychoneuroses with somatic symptoms affecting other systems in ICD-7. The term hysteria was retained in ICD-8[23] and ICD-9.[24] The term somatoform disorder was introduced in the ICD-10.[25] Dissociative and conversion disorders were grouped under a different category.

The ICD-10 diagnostic guidelines differed from those in DSM-IV somatoform disorders in many ways. The symptom threshold was reduced for somatization disorder by including “multiple and variable unexplained symptoms representing at least two organ systems.” The duration requirement was increased to at least 2 years. Somatoform autonomic disorder characterized by symptoms of autonomic arousal in the absence of any disturbance of structure or function was included as a subtype of somatoform disorders. The ICD-10 guidelines for somatoform pain disorder require persistent, severe, and distressing pain continuously for at least 6 months that cannot be explained by a physical condition which is in contrast to DSM-IV where duration has not been mentioned and emphasis has been on the psychological factors for diagnosis. Further, neurasthenia has been included in ICD-10 but is not used in any section of DSM-IV.

Further changes have been made in the upcoming revision of the ICD-11[26] in the classification of somatoform disorders. The first change that has been noted is the nomenclature. “Bodily distress disorders” is the term that has been proposed in place of somatoform disorders. The guidelines for the bodily distress disorders include the presence of persistent bodily symptoms that are distressing to the individual with excessive attention toward the symptoms. The symptoms are not alleviated by clinical examination or investigations and associated with significant impairment in functioning[26] (http://apps.who.int/classifications/icd11/browse/l-m/en#/accessed on 15 June 2017).


  Determination of Severity Top


Bodily distress disorder has been classified according to one of three levels of severity: (1) mild bodily distress disorder, (2) moderate bodily distress disorder, and (3) severe bodily distress disorder. Severity is assessed in terms of the degree of distress or preoccupation with bodily symptoms, persistence of the disorder, as well as the degree of impairment and health-care-seeking behavior. The clinician should make a global rating of severity taking into account all aforementioned dimensions rather than using a single dimension. Although these severity qualifications are not very satisfactory, as they are based on subjective quality of the distress, there are no suitable alternatives. The objective criteria for “bothersomeness” based on the number of hours spent in thinking about the symptoms may be arbitrary as there may be fluctuations in the way symptoms are experienced as well as the attention being paid at different points of time. Furthermore, “bothersome” is not a common word in usage in many places and may be misinterpreted.

The DSM-5 and ICD-11 have modified the diagnostic criteria to improve clinical utility but have not answered all the criticisms of the previous versions.[27] Both classifications are overinclusive and have the risk of medical illness being diagnosed as psychiatric illness and thus increasing stigma. Conditions such as chronic pain syndromes where the presentations can be similar to SSDs might be mismanaged.[18]

The International Association for the Study of Pain task force has put forth a proposal for the classification of chronic pain for ICD-11 wherein the criteria for chronic primary pain have similarities to DSM-5 and ICD-11 criteria/guidelines for somatic symptoms disorders and bodily distress disorders.[28]

Hypochondriasis is characterized by a lot of bodily distress, but its classification is very controversial in ICD-11. Hypochondriasis was categorized both under anxiety and fear disorders as well as under obsessive-compulsive and related disorders in different beta-versions of the ICD-11. In hypochondriasis as well as somatoform disorder, there is a preoccupation with bodily symptoms and distress. In both, the person seeks medical attention. However, the distinction is made on the basis of the person being reassured by appropriate clinical examination and investigations. Clinicians may question if this is a sufficient ground for differentiation. In bodily distress disorder also, the individual may believe quite naturally that the symptoms indicate underlying physical illness. In hypochondriasis, the fear is of a probable illness. In any given situation, this may be difficult to distinguish.

In DSM-5, the term “somatic symptom” causes confusion because the somatic symptoms of depression refer to vegetative symptoms and are not related to physical or bodily symptoms. During discussions of the ICD-11 working group, the term somatoform was considered stigmatizing and poorly understood by the persons suffering from that condition. The term bodily distress in that way is better than DSM-5 SSDs because this terminology improves the communication not only between physicians but also between the physician and the patient. Psychiatrists in the WPA-WHO global survey considered communication to be the most important purpose of diagnostic classifications. In addition, the survey also showed that somatoform disorders had a low ease-of-use or goodness-of-fit in day-to-day clinical practice.[29] The term, bodily distress disorder, is also advantageous as it better informs treatment and management decisions. For example, the “distress” of bodily symptoms needs to be evaluated, investigated, and minimized.

An issue that is not adequately addressed in both ICD-11 draft and DSM-5 is that bodily symptom in clinical practice may be[30] of different types:

  • Organic or medical
  • Psychological or psychosocial
  • Both organic and psychological
  • Neither organic nor psychological (idiopathic – the cause is not known).


The current diagnostic systems do not help a clinician either distinguish these or classify these.


  Future Directions Top


One of the authors (SKC) was part of the working group for the classification and revision of ICD-10 somatoform disorders. The challenges and difficulties in diagnosing somatoform disorders cannot be understated. The ICD-11 proposal for bodily distress disorder has to undergo testing of its clinical utility. The WHO has an internet-based platform, the Global Clinical Practice Network, which now has over 13,000 registrants who are doctors and mental health specialists who are invited to participate in studies examining the clinical utility and goodness-of-fit of some of the new guidelines for ICD-11 categories. The guidelines of bodily distress disorder need to be tested on this platform as a way of providing strong empirical support for the proposal.

Clinical experience with the criteria of DSM-5 and ICD-11 will indicate their usefulness in clinical practice. Nevertheless, one must consider other clinical classificatory systems.

There are various dimensions that need to evaluated including description of symptoms, distress, illness behaviors, cognitions, and functioning. A multiaxial classification for these bodily symptoms would probably answer some of the limitations of the current diagnostic systems. The multiaxial classification[30] could be tried to make bodily symptoms explainable and understandable, with different specifiers, e.g.,

  • Axis 1: Somatic symptom (pain, fatigue, or multiple)
  • Axis 2: With or without depression/anxiety
  • Axis 3: With or without antecedent stress or life event
  • Axis 4: With or without somatic focus/preoccupation, etc.
  • Axis 5: With or without attribution/misattribution
  • Axis 6: With or without coexisting medical disorder.


The last word for bodily symptoms has still not been said. As can be noted from the journey of disorders with bodily symptoms, there have been ups and downs, based on the contemporary theoretical flavor, from psychoanalytic to phenomenological, and may also go on to genetic, neurochemical and neuroradiological, with developments in science. [Table 1] provides the comparison of DSM-5 and ICD-11 criteria of somatoform disorders.
Table 1: Comparison of DSM V and ICD 11 criteria

Click here to view


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Conflicts of interest

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