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Classification of Somatoform Disorders

To the Editor:

Richard Mayou, M.A., M.Sc., M.Phil., F.R.C.P., F.R.C.Psych., and others (1) presented a comprehensive description of the problems of the classification of somatoform disorders according to DSM-V. Their main suggestion was to abolish the classification of patients with unexplained physical symptoms as a psychiatric disorder and to include a new axis III category for patients with "functional somatic symptoms and syndromes." We argue that improving rather than abolishing the classification would be the preferred route for DSM-V and ICD-11. Expectations that anything would improve if the category of somatoform disorders is abolished are unwarranted. Our major comments are the following:

1. Patients with these complaints represent one of the major groups of patients with abnormal health care use, increased sick leave days, and early retirement. Therefore, a clear diagnosis is needed.
   
2. Former diagnoses (e.g., hysteria, neurasthenia, functional syndromes, and psychosomatic complaints) were stigmatizing, unreliable, and rarely used even in psychiatry. The category of somatoform disorders improved the description of syndromes and the reliability of classification and was the basis of an overwhelming development in psychiatry.
   
3. We do not need more axis III categories (as suggested by Dr. Mayou et al.) but fewer. ICD-10 already includes a long list of syndromes describing patients with unclear somatic complaints (e.g., dyspepsia, functional stomach disorder, irritable bowel syndrome, different headache types, back pain). There is strong evidence that these diagnoses frequently describe the same patient with multiple somatic complaints (2). One of the benefits of DSM-III was to offer one diagnosis for patients with multiple functional symptoms affecting multiple body sites.
   
4. The missing acceptance of the diagnosis of somatoform disorders is not a question of the term. Patients’ acceptance of the diagnosis depends on the explanation of the term provided by their doctors. Doctors’ acceptance of the category was not improved by any of the psychiatric or axis III diagnoses offered for patients with functional somatic complaints in the past. Doctors’ acceptance of the category will improve with increased knowledge and guidelines of how to explain the diagnosis and how to manage these patients.
   
5. Most research and treatment suggestions of somatoform disorders came from mental health specialists. We should not risk stopping these activities by abolishing a DSM category. As we mentioned, there is no reason to hope that medical specialists will be more interested in somatoform disorders if a new axis III diagnosis is introduced.
   
6. It is necessary and worth improving the existing approach of classification under the category of somatoform disorders. Empirically validated criteria for symptom lists and cutoff scores, as well as psychological features, should be used to redefine the disorder (3). The modifications of the classification should respect new epidemiological and clinical findings.
   

References

1. Mayou R, Kirmayer LJ, Simon G, Kroenke K, Sharpe M: Somatoform disorders: time for a new approach in DSM-V. Am J Psychiatry 2005; 162:847–855[Abstract/Free Full Text]
2. Wessely S, Nimnuan C, Sharpe M: Functional somatic syndromes—one or many? Lancet 1999; 354:936–939[CrossRef][Medline]
3. Rief W, Hiller W: Toward empirically based criteria for somatoform disorders. J Psychosomatic Res 1999; 46:507–518[CrossRef][Medline]

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