Author's response to letters from Shröder and van der Feltz-Cornelis
We are pleased that the authors of these letters appreciate our efforts to be open regarding the proposed changes to the diagnostic criteria of the Somatoform Disorders chapter of DSM-IV [1], [2]. It is gratifying also that they concur with our impression that the DSM-IV chapter needs extensive modification and they have made valuable contributions to the debate regarding these criteria. We agree with the suggestion in both letters that we should avoid the unhelpful terms ‘somatoform’ and ‘medically unexplained.’
Schröder and Fink [1] comment on the three criteria that have been proposed for the comprehensive diagnosis, provisionally entitled “Complex Somatic Symptom Disorder.” With regard to the first criterion point, we note their concern that the draft description, as provided in our article, seemed to give undue emphasis to matters such as patients' difficulty coping with, and tolerating, physical discomfort. As a result of this and other feedback, we are likely to modify this section. What we are striving for is a description of the disorder that is precise and unambiguous.
We do respect the knowledge and experience of clinicians treating patients with “severe and chronic functional symptoms and somatization disorder,” but our proposed definition must define a much broader group of patients than this, including those seen frequently in primary care. Population surveys are therefore relevant, but we read the evidence differently from Schröder and Fink [1]. We do not interpret existing evidence as indicating that medically unexplained symptom clusters into gastrointestinal, cardiopulmonary, and musculoskeletal clusters “with specific neurobiological disturbances underlying these clusters.” Schröder and Fink [1] quote their own study in this respect together with several others in Table 1, but they omit three other important studies [3], [4], [5] all of which found evidence for a single factor underlying a large number of symptoms. Both the study of Deary [6] and a systematic review concluded that the data do not provide convincing support for a consistent picture of the clustering of somatic symptoms [7]. We believe therefore that it is premature to conclude that clusters of symptoms with specific underlying neurobiological disturbances can be used to build a diagnostic scheme. By proposing a single, inclusive diagnosis of complex somatic symptoms, we aim, in this section of DSM-V, to allow future research to test whether particular patterns of symptoms are indeed supported by epidemiological research and whether these are found to have biological substrates. We guard against making premature subdivisions which may limit the usefulness of future research.
The same approach would prevent us from accepting the evidence provided by Schröder and Fink [1] that health anxiety should be defined as a separate category from that primarily representing numerous bodily symptoms. We regard this as a premature conclusion as, once again, the evidence of overlap between numerous bodily symptoms and health anxiety is very considerable, up to 60% according to one study [7] and nearly 50% in Fink's own study [8].
With regard to our third criterion, increased pattern of health care use, Schröder and Fink [1] reject this as a basis for making a diagnosis. In their view, the “evidence is ‘unequivocal’ that the Health System as a whole and the doctor/patient consultation in particular assume an important role in the initiation and maintenance of so called medically unexplained symptoms.” They think therefore that it is wrong to blame the patient for what they regard as shortcomings in the health care system and doctor's lack of communication skills. The workgroup accepts the evidence that there are difficulties in some doctor–patient encounters for the patients in this group and we have been exploring ways of operationalizing the unsatisfactory nature of the utilization.
In their letter, van der Feltz-Cornelis and van Balkom [2] support the suggestion, previously made by Mayou et al. [9], that the whole category of somatoform disorders be scrapped. They suggest (a) that the majority of patients previously diagnosed as “somatoform disorder” could be encompassed in the diagnoses of depressive or anxiety disorder and (b) that these latter diagnoses could be enhanced by subcategories indicating that the depression or anxiety is accompanied by pain, somatic presentations, or hypochondriacal worries.
In our editorial, we acknowledged the close association between the presence of multiple bodily symptoms and anxiety/depression but commented that only about half of primary care patients with high somatization scores also have high anxiety or depression scores [10]. Furthermore, successful treatment of multiple somatic symptoms may be achieved without change in depression or anxiety, casting doubt on the notion that the depression or anxiety is the primary disorder [11]. In addition, it has been shown that numerous bodily symptoms have an association with outcome independent of anxiety and depression [10]. The larger DSM taskforce is considering carefully the question of hierarchy of diagnoses. While this matter is still under discussion, considerable sentiment has been expressed in favor of allowing multiple psychiatric diagnoses, rather than forcing them into a hierarchy. Thus, psychiatry, like the rest of medicine, may list a number of disorders (e.g., complex somatic symptom disorder plus depression), if present, rather than assume that one disorder accounts for another. Allowing diagnoses under both chapters of DSM-V (somatic symptom disorder and mood or anxiety disorder) may be more realistic in the current state of knowledge rather than asking clinicians to choose between them.
Van der Feltz-Cornelis and van Balkom [2] suggest that the minority of patients who do not have a depressive or anxiety disorder could be classified as “medical symptoms or medical illness with non-compliant treatment” or “multi-symptomatic, medically unexplained symptoms with non-compliant treatment.” The basis for describing these symptoms as “noncompliant with treatment” is not entirely unclear but appears to refer to the fact that these patients are presenting to doctors with bodily symptoms when the underlying problem, for which they might seek help, is really depression. This does not appear to us to be a particularly helpful diagnostic category. We doubt that terms such as “noncompliance with treatment” will improve the doctor–patient relationship or lead to successful treatment for these patients who seek treatment for their bodily symptoms. To a certain extent, however, problems of noncompliance are part and parcel of the current diagnosis of “psychological factors affecting medical condition,” a term that, if somewhat long and awkward, still manages to convey important information.
We appreciate the comments made in these two letters and believe the feedback such as they have provided can only be helpful in helping us to formulate the most accurate and useful definitions at this stage of knowledge. These comments have been discussed within the workgroup and we will certainly be open to further comments. Revisions to our draft criteria will be posted from time to time on the APA's website (http://www.psych.org/dsmv). If readers wish to make additional comments, please email us at LJawdat@psych.org.
FULL TEXT