4. Medically Unexplained Symptoms in DSM-5

Changes to the Somatoform Disorders section of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association potentially will have greater practical impact than revisions of any other section.  This will be the case if the tens of millions of  patients (in the U.S. alone) with physical symptoms connected to psychosocial stresses are given an appropriate diagnostic term.  To that end, I offer the following ideas to revise the Somatoform Disorders section in the next edition, the DSM-5.

First, change the name from Somatoform Disorders (a term used almost exclusively by mental health professionals) to Psychosomatic Disorders, which is understood by everyone.  Patients object to being labeled with a term that contains the prefix “psycho-” but it will not be used as a diagnosis, merely as the name of the category.  The category will include five distinct clinical conditions: Somatization Disorder, Psychological Factors Affecting Organic Disease, Hypochondriasis, Factitious Disorder and a new definition for Complex Somatic Symptom Disorder (CSSD).  The latter will include Stress Illness patients (1) plus those previously diagnosed with Somatoform Disorders, Pain Disorder Associated With Both Psychological Factors and a General Medical Condition, and Pain Disorder Associated With Psychological Factors.  More formally, CSSD would now be defined as follows:

A.  One or more somatic symptoms that are distressing and not fully explained by the results of diagnostic tests.

B.  Symptoms improve in response to diagnosis and treatment of one or more of the following associated conditions:

(1) Ongoing social or psychological stresses including insufficient self-care skills.

(2) Prolonged effects from childhood of neglect or psychological, physical or sexual abuse.

(3) Depression.

(4) Post-Traumatic Stress Disorder.

(5) Anxiety Disorder.

C.  Symptoms may be of any duration and may not be continuously present but severity tends to correlate with fluctuations in severity of the conditions listed under B.

Discussion of this proposal follows in the next post.

1. Stress Illness is the term I use for patients whose physical symptoms are not fully explained by diagnostic tests but improve when psychosocial stresses are treated.

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