Prepared by Michael B. First, M.D., DSM Consultant to the American Psychiatric Institute for Research and Education (APIRE), a subsidiary of the American Psychiatric Association
The APA, in collaboration with the WHO and NIH, convened a diagnosis-related research planning conference focusing on somatic presentations of mental disorders in Beijing, China, on September 6-8, 2006. The conference was the eighth in a series of 12 NIH-funded conferences on "The Future of Psychiatric Diagnosis: Refining the Research Agenda" that is administered by APA's American Psychiatric Institute for Research and Education (APIRE). The Somatic Presentations conference co-chairs were Joel Dimsdale, MD, University of California San Diego (La Jolla, CA), Yu Xin, MD the Institute of Mental Health Peking University Bejing, China), Arthur Kleinman, MD, Harvard University (Cambridge, MA), and Vikram Patel, PhD, London School of Hygiene and Tropical Medicine (London, UK). Twenty-eight invited scientists from around the world participated.
Ricardo Araya MD (Bristol, UK), speaking on the epidemiology and association of somatoform disorders and common mental disorders in community and primary care settings, noted that it is impossible not to approach depression and anxiety without considering the presence of unexplained physical symptoms. He emphasized, however, that the absence of a medical explanation should not confer automatic psychiatric labeling. With respect to the validity of the somatoform disorders, he identified several noteworthy issues, including: 1) somatoform disorders are highly comorbid with depression and anxiety in most community and primary care studies, although a small group of individuals present with a somatoform disorder alone; 2) in the WHO-PHC study, mood, anxiety, and somatoform symptoms loaded into one common factor ('internalizing' disorders) in all countries surveyed; and 3) a large longitudinal community survey in Germany found there was marked mobility over time between somatoform diagnostic categories. Regarding reliability, recall of symptoms in primary care settings is markedly inconsistent; in one follow-up study involving individuals who initially reported somatic symptoms, they could not recall 61% of those symptoms 12 months later. Furthermore, test-retest, inter-rater reliability, or internal consistency of measures is mostly unknown. The clinical usefulness in primary care settings also warrants attention; although unexplained somatic symptoms are common in primary care throughout the world, the complexity of the diagnostic categories discourages their widespread use in primary care outside developed countries, he reported. Discussant Roseland Lieb, PhD (Basel, Switzerland) noted the remarkable association (both current and lifetime) between somatoform disorders (including subclinical forms of somatization disorders) and anxiety/mood disorders. Among the possible explanations she offered for this association are symptom overlap across categories, reporting bias(i.e., subjects affected by one disorder tend to report more symptoms of the other disorder), one disorder causing another disorder, and shared vulnerability factors. One method for exploring questions of comorbidity is to compare the age at first onset of the various disorders. The different somatoform disorders appear to have different patterns of age of onset; for example, undifferentiated somatoform disorder has an early onset but conversion and pain disorder have a much later onset, typically after the onset of mood and anxiety disorders. She concluded by pointing out that although there is no clear empirical distinction between mood, anxiety, and somatoform disorders, lumping them together cannot resolve the problem of how they fit together.
Simon Wessely, MD (London, UK) presented on the association between the various functional somatic syndromes seen across medical specialties (e.g., irritable bowel syndrome, fibromyalgia, atypical chest pain, tension headache, etc.). Overall, unexplained medical symptoms are common in primary care settings (occurring in more than 50% of patients in one study). There is tremendous overlap among the symptoms included in the definitions of the various functional syndromes so that the more symptoms you have that are characteristic of one syndrome, the more likely one is to have symptoms characteristic of the other syndromes as well. Despite a significant association of the functional syndromes with depression or anxiety, the modest effect size (0.68) indicates that depression and anxiety do not entirely explain the functional syndromes. Furthermore, population-based studies of fatigue suggest that there is a reasonably stable set of neurasthenia cases (i.e., fatigue syndrome) that do not overlap with depression and anxiety. A latent class analysis of functional somatic symptoms in the community suggests the presence of five classes: a chronic fatigue-like entity, a pan/myalgia-like entity, an irritable bowel syndrome-like entity, a depression entity, and an anxiety entity. Dr Wessely concluded that we should accept the existence of a concept of functional somatic symptoms/syndromes that differ from anxiety and depression, and that within this broad category we still need to respect the integrity of fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, and their cultural variants. In his discussion, Jean-Pierre Lepine, MD (Paris, France) agreed that the functional somatic syndromes were associated with each other, citing a large Swedish twin registry that found a number of significant co-occurrences among the syndromes. . Emphasizing the need to take culture and language into account, he noted that in France, for example, irritable bowel syndrome is called chronic spasmodic colitis.
Laurence Kirmayer MD (Montreal, Canada) presented on the role of cultural models in the phenomenology of somatoform disorders. Cultural models, he explained, are diverse models for symptoms, afflictions, causal explanations, and social and moral meaning. Typically multiple models are brought to bear to explain distress. When considering cultural models in the diagnosis of somatoform disorders, one needs to understand what has shaped a person's experience of his or her body. It is important to keep in mind that classification of mental disorder is itself a cultural artifact; for example, depression was not reported in Japan prior to the widespread adoption of the DSM and ICD diagnostic systems and the promotion of the term through popular media and pharmaceutical marketing. Although epidemiology and clinical diagnosis both assume an indexical relationship between symptom reports and underlying physiology and experience, the relationship is embedded in and mediated by cognitive and social processes. The cognitive bases of cultural models include 1) explanatory models, which involve explicit notions of cause, course, outcome, and proper treatment, which are shaped by local theories of body, person, society, and adversity; 2) prototype models, in which experiences of self or others as explicit models or salient images are used to reason analogically about current illness experience; and 3) chain complexes, in which implicitly learned sequences of events, habits or practices structure thinking. These models are not static cognitive representations or ways of reasoning within the individual. There are also dynamic "looping effects" in which various cognitive processes and social responses can lead to more symptoms. In hypochrondriasis and culture-specific variants of panic disorder, for example, the presence of symptoms lead to specific causal attributions, which in turn trigger catastrophic interpretations that lead to increased emotional arousal and, consequently, additional symptoms. Similarly, in chronic fatigue syndrome, symptoms lead to activity restriction which in turn leads to more symptoms. Dr. Kirmayer proposed that looping effects should be considered core mechanisms of psychopathology that can be studied in their own right and made central to a revised nosology, with clear links to specific interventions. Concluding that the entire category of somatoform disorders is largely the consequence of a dualistic ontology and epistemology that is reflected in the structure of biomedical health care, he suggested that it might make sense to eliminate the category in favor of a process-oriented assessment of psychosocial factors affecting physical condition. In his discussion, Norman Sartorius MD, PhD (Geneva, Switzerland) raised a number of questions about cultural models. Is it necessary to pay much attention to specific cultural influences that with globalization cultures are becoming more similar? Is it worth describing culture-specific phenomenon if cultures vanish? Given that the best observers are those who are part of the culture, if they are to communicate with others outside their culture using a common idiom, will they consequently be able to truly represent their culture and mental disorders specific to it? Cultural models are built or held by the general population, by the medical community, by cultural anthropologists, and by insurance companies-which one should be promoted or accepted for communication? Should any of the described idioms of distress be included in DSM or ICD? Are there sufficient data to call them diseases? Is it time to admit that there are no culture-specific disorders but that all types of disorders happen in all cultures albeit with a different frequency?
Javier Escobar, MD (Piscataway, NJ) addressed a number of topics concerning the epidemiology of somatoform disorders and ethnicity. He noted first that it is important to assess somatoform symptoms because new effective treatments are emerging and because somatoform symptoms may complicate the treatment of other disorders (e.g., increased rates of reported side effects of medication and higher levels of symptoms and functional impairment). Serious nosological problems exist, however, particularly for the definition of somatization disorder, which has changed significantly across the DSM editions, resulting in widely varying prevalence figures in primary care settings and poor concordance with the ICD-10 definition. Also problematic is the definition of race and ethnicity in the United States. Race/ethnicity defines the ways in which one sees oneself and is seen by others, Dr. Escobar said. Common elements include skin color, religion, language, ancestry, and customs. Ethnicity boundaries are dynamic, imprecise, and a difficult concept to define operationally; for example, the Hispanic (Latino) group is particularly heterogeneous, with origins in more than 20 countries and often containing various racial admixtures. Epidemiological studies looking at prevalence of somatoform disorders in different countries yield widely varying results (0-18%). Most studies noted a close association between somatization and symptoms of anxiety and depression. He recommended defining ethnicity more precisely for classification purposes, and including somatoform symptoms in epidemiological surveys (recent surveys have not); with respect to DSM-V, he suggested that workgroups consider adding a somatic specifier (e.g., depression with or without significant somatic symptoms) and/or an additional axis for functional somatic symptoms. Commenting on the presentation, Richard Mayou FRCP (Oxford, UK) noted that, in all cultures, somatic symptoms are not due to pathology but are associated with disability, and consultation is common. Wide variations in symptom patterns, labels, and explanations notwithstanding, there is no evidence of differences in psychological processes. While somatic (or functional) experiences are universal, there are large cultural differences in understanding of meaning, communication with healers, explanations and advice given by healers, social attitudes to validity, and need for treatment. Current research has produced conflicting results due to the use of varied definitions of "somatization," and has been hampered by a narrow definition of "culture." Future research addressing "cultural" influences should use identical ascertainment procedures and similar recruitment settings using uniform (perhaps multiple) definitions and should take into account the "culture" of doctor-patient interactions.
Elizabeth Lin MD (Seattle, WA) presented on the somatic burden of co-occurring depression and anxiety in chronic medical illnesses. Depression is highly prevalent in a number of chronic medical illnesses, including diabetes (10-20%), heart disease (20- 30%), chronic pain (40-60%), cancer (10-20%), and neurological disorders (10-20%). The question is not which came first, but how do these interplay? When depression and anxiety co-occur with such illnesses, there is less treatment adherence and self-care, more functional impairment, higher use of medical services, and increased complications and mortality. Dr. Lin and colleagues reviewed the literature focusing on arthritis, heart disease, diabetes, and congestive heart failure (CHF)/asthma/emphysema. For arthritis, anxiety and depression is strongly linked to pain severity. Successful treatment of depression results in less pain and less interference with daily life. For diabetes, anxiety and depression is related to neuropathic pain and to the number of diabetes symptoms, but not to hemoglobin A1C (a measure of blood glucose control). For coronary artery disease, depression and anxiety are related to angina and decreased exercise capacity; after a myocardial infarction, a history of depression is related to increased angina frequency. In contrast, physiological measures (e.g., ejection fraction and ischemia measures) were not significantly related to angina. For CHF, asthma, and emphysema, depression and anxiety were significantly related to dyspnea and fatigue, whereas pulmonary functions tests were not. Dr Lin concluded that in chronic medical illnesses it is crucial to assess and treat mood and anxiety disorders. In his discussion, Yu Xin, MD (Beijing, China) noted that there is a higher prevalence of somatoform disorders in elderly patients and that health care providers need to take into account cognitive function, which can influence expression of mood symptoms and communication with physicians. He also noted that cultural differences were of great importance in the treatment of patients with somatoform disorder. Language, in particular, is especially important in culture; in the Chinese language, somatic words are used to indicate emotions: "trouble in heart" means anxiety, "headache" means feeling annoyed, "suffocation of heart" means depressed mood, and "body is withered" means fatigue and loss of energy. Furthermore, the symptomatology of depression and anxiety in chronic medical illness need to be further studied as it may differ from what we see in "pure depression" in terms of clinical manifestations. For example, studies have shown that demoralization was more prominent than anhedonia for the diagnosis of depression concurrent with medical illness.
Sing Lee, FRCPsych (Hong Kong, China) presented a historical perspective, asking whether somatoform disorders are changing with time in relation to prevailing social attitudes and values. DSM-III held that the category of somatoform disorders would be very useful in non-Western communities given that mood disorders had low prevalence outside the Western world. This has not happened, however, as depression now is the language of distress among mental health professionals in Chinese urban settings. The story of "neurasthenia" reflects the history of Chinese assimilation of the Western professional culture. From the 1950's to 1980, before China had expanded interactions with western nations, neurasthenia was the most common neurotic disorder (80-90% of outpatients received the diagnosis) and was not the same as chronic fatigue syndrome (CFS). Neurasthenia in the Chinese context was a broadly defined condition characterized by weakness, emotional symptoms, sleep disturbance, nervous pain, and excitement symptoms. During the period from 1980 to 1995, with the failure of DSM-III and DSM-III-R to recognize neurasthenia and Kleinman's seminal study indicating that 87% of Chinese patients with neurasthenia could be rediagnosed as having DSM-III depression, the Chinese concept of neurasthenia was marginalized in favor of Western concepts of depression. After 1995, neurasthenia has rarely been used in big cities in China. In the latest version of the Chinese classification system (CCMD-3), the diagnosis of neurasthenia requires that one exclude depression, anxiety, and the somatoform disorders first, which makes the diagnosis of neurasthenia virtually unnecessary. The story of neurasthenia in China may to some extent guide attempts to understand the disappearing course of other culture-bound syndromes in the East where psychiatry is also undergoing transformations under global forces such as the DSM system and pharmaceutical marketing. In his discussion, Xiao Zeping, MD (Shanghai, China) raised the question of whether psychiatrists need to educate patients to speak our professional language or rather should we try to understand them on their own terms. In China there is great variation in the practice of psychiatry among different provinces and cities and between rural and urban areas. Chinese traditional medicine has its own philosophy and diagnostic system with a long history and deep influence on Chinese daily life and general thinking. Most Chinese medical professionals are now educated about western medicine, which raises questions about how to integrate western medicine with Chinese traditional medicine.
Joel Dimsdale, MD (La Jolla, CA), in a presentation on biological substrates for somatoform disorders, began by noting that behind many somatoform patients lurks an undiagnosed disease. He identified four ways in which unrecognized diseases get labeled as somatoform disorders: 1) missed diagnoses (in a small sample of fatigued breast cancer patients, 40% had undiagnosed thyroid disease); 2) new diagnostic tests reveal surprisingly prevalent diseases (e.g., celiac disease, once considered rare and diagnosed primarily in childhood is quite common); 3) new insights about fatigue and pain (e.g., sleep disruption contributes to pain and fatigue); and 4) new, previously unknown diseases are discovered (e.g., SARS, hepatitis C). Dr. Dimsdale stressed the importance of "getting beyond the black box" and using lab data to try to understand the underlying somato-psychic phenomena. One area of potentially fruitful study is the process of somatic amplification and de-amplification, i.e., what determines the "volume level" of distress. Neural imaging offers enormous potential, particularly for amplification and de-amplification of pain (e.g., brain regions show similarities and differences during laser and suggestion-induced pain). Genetic approaches to understanding underlying pathophysiology are also likely to be helpful (e.g., the CDC international collaboration to study chronic fatigue syndrome is integrating psychiatric, sleep, genetic, epidemiologic, and neuroendocrine investigations). In his discussion, Robert Dantzer DVM, PhD (Urbana, IL) described the potential importance to the experience of physical symptoms of the immune system-to-brain communication pathways. He proposed a mechanism by which manifestations of physical problems may be mirrored in the brain: pathogen-associated molecular patterns and bodily danger signals lead to the release of peripheral cytokines, which are recognized by the brain and lead to brain cytokines (internal representations of sickness), which, in turn,, which are experienced as non-specific symptoms of disease (e.g., anorexia, anhedonia, cachexia, pain, GI distress, cognitive disorders, mood alternations, and fatigue). Normally this system is accurately regulated; that is, it is geared to be triggered in a temporal manner and is usually transient. Somatic disease with an inflammatory component would thus induce both dysfunction at the target organ as well as sensitizing brain sickness systems, leading to internal representation of sickness with an entire array of non-specific symptoms. If the sickness system is sensitizing the brain, then other systems, such as psychological conflict, could trigger it as well.
Michael Sharpe MD (Edinburgh, Scotland) in his presentation, considered whether there are consistently demonstrated psychosocial risk factors for somatoform disorders and, if so, whether they are shared across syndromes. Risk factors are identifiable factors that make a condition more likely to occur; it is important to understand that they are not necessarily a cause (i.e., an understanding of psychosocial risk factors will not explicate the mechanisms involved and are most helpful in prevention). Specific risk factors for somatoform disorders, given the limited available data, probably include female sex, childhood experiences, previous history, iatrogenesis (clinically seen but limited data available), physical stress and trauma, and having a psychological predisposition. Although most of these risk factors are likely common to all of the somatoform disorders, there may be some differences (e.g., the relationship between abuse and conversion disorder). Future research methods should include large surveys and case-control studies, prospective cohort studies, and studies that integrate psychology with biology (brain imaging and animal experiments). In his discussion, Winfried Rief, PhD (Marburg, Germany) wondered whether the above mentioned risk factors are relevant to the development of symptoms, or rather are risk factors for maladaptive coping when symptoms occur. Anxiety, depression, and somatoform disorders are interdependent risk factors; if someone has anxiety or depression, then they are at increased risk for developing a somatoform disorder. Factors which somatoform, depressive, and anxiety disorders have in common include comorbidity, traumatization, lower social status, family history, cultural variations, increased health care use, seeking treatment in primary care, reporting physical symptoms to general practitioners, and immigration. Possible psychosocial correlates which may be more specific to somatoform disorders and that should be considered for inclusion as part of the definition of somatoform disorders include attention-focusing on physical perceptions, over-interpretation of physical sensations as possible illness signs, illness worries and rumination, seeking medical reassurance, failure of medical reassurance, demoralization, negative affectivity, physical deconditioning, and avoidance behavior.
Deborah Hasin, PhD (New York, NY) began her presentation on the interaction between substance use disorders and somatic presentations with the observation that the literature is extremely sparse on this comorbidity. She presented a table depicting the overlap between the symptoms of substance intoxication/withdrawal and somatoform symptoms. Given that somatoform disorders are rare in the general population, even fairly large epidemiological studies of substance use yield too few comorbid cases for analyses. Although the prevalence is higher in specialized psychiatric or primary care samples, the generalizability of these samples is unknown (for example, among a convenience sample in the United States, substance use disorders were diagnosed in 25-49% of the body dysmorphic disorder patients). A Swedish adoption study showed that individuals had higher rates of somatoform disorders if their biological fathers abused alcohol or were treated for alcohol abuse. Furthermore, among samples of primary care patients in the United States, full or subthreshold somatization disorder predicted higher rates of alcohol use in relatives. Dr Hasin noted that, from a research perspective, the large number of symptoms that need to be assessed to make a somatoform diagnosis discourages inclusion of these disorders in more studies. In his discussion, Chen Yanfang MD (Beijing, China) commented on the complexity in assessing symptoms in this area, and presented his Rating Test for Health and Disease (RTHD), which assesses and classifies mental and physical symptoms associated with both mental disorders and physical diseases. The patient at home can use the RTHD-P (patient version); followed up by the RTHD-C clinical version. One of the trials of RTHD was conducted to assess the stability of alcohol abuse in a multiaxial fashion.
Winfried Rief, PhD (Marburg, Germany) presented on the diagnostic stability of somatoform symptoms over time. He began by showing the results of several empirical studies that demonstrated: 1) patients have problems recalling lifetime symptoms; 2) the reduction of physical functioning in somatoform disorders is a stable feature; 3) patients with multi-somatoform disorders were less likely to improve over time than patients with fewer medically unexplained symptoms; 4) the number of symptoms predicts outcome even after correcting for anxiety, depression, and health anxiety; 5) somatic complaints are a strong predictor of bad outcome in pharmacological depression trials; 6) the time pattern of recovery is different for depression symptoms than for pain symptoms; and 7) during antidepressant treatment, depressive mood disappears, but somatic symptoms tend to persist. Regarding the issue of whether somatoform symptoms are actually undetected physical disease, in scientific trials less than 10% of the diagnoses had to be modified because of non-detected medical conditions. Furthermore, the rate of misdiagnosed organic conditions seems to be comparable between somatoform disorders, anxiety, and depression. These findings, said Dr. Rief, have the following implications for future classifications: 1) symptoms may vary, but the syndrome seems to be stable; 2) because of problems with recalling lifetime symptoms, the classification should focus on present state symptoms or the last seven days; 3) the term "medically unexplained" should not be used as a criterion; instead, the criteria should continue to use "the symptoms are not fully accounted by an (other) known medical condition" and 4) patients with polysomatoform symptoms show different course and outcome features than patients with depression or anxiety. Dr Rief proposed changes in the classification of somatoform disorders, including modifying the criteria for somatization disorder by including further descriptive criteria for the syndrome (attention-focusing; avoidance; etc.); and modifying the criteria for hypochondriasis by removing the criterion which states: "the preoccupation persists despite adequate medical reassurance." In her discussion, Maria Graceiela Rojas Castillo, MD (Santiago, Chile) noted that in the developing world there is only one prospective study on somatoform disorders; that research on somatization disorder is difficult because it is expensive; and that there is lack of clarity about the exclusion criteria. She questioned why a physician should make a diagnosis of somatization disorder unless he/she has something to offer to the patient.
Athula Sumathipala, MD (London, UK) reviewed treatment intervention studies for somatoform disorders. Studies of pharmacological interventions support the use of tricyclic antidepressants, SSRIs, and MAO inhibiters; a systematic review of 94 randomized controlled trials on six symptom syndromes concluded that antidepressants could be effective for symptoms and disability but that side effects were an issue. Reviews of studies of psychological interventions concluded that cognitive-behavioral therapy (CBT) may be efficacious for either defined symptom syndromes or for the broader category of medically unexplained symptoms. The impact of CBT ranges from a reduction of physical symptoms to a reduction in psychological distress and disability. However, further studies with high quality design are needed. Only limited evidence exists for psychodynamic psychotherapy, family therapy, problem solving approaches, reattribution, eliciting the patient's explanatory model, and structured care by one therapist. Moreover, in studies completed to date, limitations include: 1) studies were carried out using different forms of psychotherapies and adopted divergent selection procedures, interventions, outcome measures, and instruments, hampering efforts to compare treatment effects between studies; 2) most trials assessed only short-term outcomes; 3) although medically unexplained symptoms are much more common in primary care, of the meager number of intervention studies, none were conducted in primary care; and 4) economic analyses of the cost or benefits of psychological therapy were non-existent. In her discussion, Susan Levenstein, MD (Rome, Italy) a general internist, noted that a physical symptom is not a psychiatric disorder even if it is worsened by stress or distress (so is coronary artery disease) and even if it is medically unexplained (which is often a code word for MD frustration or ignorance). An overemphasis on psychological components in functional disorders may breed diagnostic sloppiness and lead to therapeutic nihilism. When medically managing patients with excessive somatic concerns, the physician must detect and treat depression, be patient (these problems go on for a long time), should schedule frequent visits with repeated reassurances, be slow and selective with psychiatric referrals, and strive to build a strong therapeutic alliance, shifting from conflict to collaboration with the goal of trying to help the patient feel better. Dr. Levenstein proposed the following principles for alliance building: 1) take symptoms seriously and empathize with suffering; 2) take an interest in the patient's life situation and psychological state; 3) inquire about the influence of psychological factors on symptoms; and 4) do not rush to communicate perceived links between psyche and soma.
Richard Mayou FRCPsych (Oxford, UK) presented on whether treatments for common mental disorders are also efficacious for somatoform disorders. The most specific treatments of mental disorders are effective when there is comorbid anxiety or depression; for somatoform disorders like hypochondriasis and body dysmorphic disorder; and when the treatments have analgesic or other specific actions. General measures (e.g., explanation, information, guidance, and reassurance) are effective in mental disorders, functional symptoms and maladaptive reactions to major physical disorders. Nonspecific, but well-defined interventions have a major role, especially in early non-specialist phases of care. Regarding issues of classification, Dr Mayou argued that 1) somatoform disorder have helped to focus attention but have impeded understanding and effective care, and that classifying physical symptoms on Axis I has been unhelpful; 2) operational Axis III definitions should be promoted; 3) treatment evidence is consistent with proposals to reassign certain somatoform disorders to other categories (i.e., hypochondriasis, BDD); 4) Psychological Factors Affecting Medical Condition (which may need a new name) should be rewritten, perhaps including Winfried Rief's more psychological criteria for multi-somatoform disorder (e.g., attention focusing on physical perception, over-interpretation of physical sensations as possible illness signs, illness worries, rumination, avoidance behavior, etc). In his discussion, Ji Jianlin MD (Shanghai, China), noted that the gold standard in the treatment of patients with somatoform disorders is a long-term empathic relationship with a primary care physician. The goal of treatment includes: 1) care for the patient, but not necessarily to "cure" the somatization; 2) ruling out concurrent physical disorders; 3) removing any conversion or pseudoneurological symptoms; and 4) maintaining or improving the patient's overall functioning. While it appears that common treatments for mental disorders are also effective for somatoform disorders, there need to be more randomized controlled trials and especially trials on the different subtypes of somatoform disorders because these are a spectrum of disorders rather than a single disorder.
Kurt Kroenke MD (Indianapolis, IN) presented on the evidence for a differential response to specific treatments for subcategories of somatoform disorders. He reported that CBT has been studied in all disorders (except conversion) and that it was found beneficial in 13 of 14 studies he reviewed. For somatization disorder (and its variants), a consultation letter to the general practitioner (GP) was effective in most studies, whereas the benefits of GP training have not yet been established. SSRIs are effective for treating body dysmorphic disorder. Antidepressants have been less well studied for other somatoform disorders. He found no proven therapy for conversion disorder and no randomized controlled trials for pain disorder or undifferentiated somatoform disorder. Both CBT and antidepressants are effective for functional somatic syndromes. In his discussion, Javier Garcia-Campayo, MD (Zaragoza, Spain), noted the many methodological limitations of these treatment studies, including nosological limitations (e.g., agreement between DSM-IV and ICD-10 criteria is low, and most research carried out is on functional somatic syndromes rather than somatoform disorders); design limitations (e.g., studies did not control for comorbid depression and anxiety); and, for the psychotherapy studies, the treatments were not manualized. He concluded that 1) there has been little research on the treatment of somatoform disorders using DSM/ICD criteria as such; 2) differences in response to treatments by subcategory support to the nosological validity of these categories; and 3) the quality of future research can be improved (e.g., evaluate somatic symptoms, psychological distress, and function, and do two-year follow-up to evaluate decay effects).
Upon conclusion of the presentations, participants reconvened in two breakout groups to formulate recommendations for research and suggestions for future versions of the classifications of mental disorders (e.g. in the DSM-V, ICD-11 and others). The first group noted that the classification of somatoform disorders in all of the available systems (i.e., DSM-V, ICD-10, CCMD-3) reproduce dualism, none are acceptable to the vast majority of patients, and all are too complex to be used by those who need to use them (e.g., primary care physicians). Possible improvements include 1) changing hypochondriasis to "health anxiety;" 2) producing specific mediating criteria for psychological, behavioral, or cognitive symptoms on axis I (e.g., fibromyalgia on axis III, avoidance behavior on Axis I); 3) continuing to include on Axis I a multi-symptom, chronic somatization-like disorder category with a better name (suggestions included "somatic distress disorder" and "somatic syndrome disorder") ; 4) considering the elimination of clauses in the diagnostic criteria requiring that "the symptoms cannot be fully explained by a known general medical condition" and 5) reconsidering the value of the neurasthenia diagnosis. Future research should focus on 1) developing a new definition for a polysymptomatic disorder; 2) operationalizing the psychological, behavioral, social, and health-seeking behaviors that characterize an axis I somatoform disorder; 3) getting stakeholder views (GPs, physicians, and patients) on classification before we tell them what to do; and 4) extending the WHO primary care study to include somatoform disorders.
The second breakout group noted that while the category of somatoform disorders has the advantage of emphasizing the salience of psychosocial issues in medical conditions, disadvantages and limitations include 1) unfamiliarity on the part of primary care physicians with these diagnoses; 2) limited explanatory power compared to traditional medical terms; 3) inclusion in this category of a mixed bag of conditions, each of which is heterogeneous, (e.g., IBS), and some of which are better known or studied by certain sectors; 4) an implied psychogenic component, which perpetuates body-mind dualism; and 5) the requirement for ruling out of medical diseases is especially difficult in developing world. The group's suggestions included: 1) use words that make sense to patients; 2) maintain better links with physicians and conduct collaborative research; 3) make the system simpler for clinicians to use while considering a multiaxial approach for researchers; 4) split or reposition the mix of conditions (i.e., BDD, conversion, somatization disorder are very rare in the community compared to somatic symptoms); 5) develop cross-culturally sensitive text descriptions; 6) clarify the concepts first before framing research questions; and 7) consider possible new names for this category including "somatic syndrome disorder," "neurosis," "psychosomatic disorder," and "somatoaffective syndromes."
Selected papers based on the presentations will be published in a future volume of the journal Psychosomatic Medicine (Summer 2007) and all papers will appear in a monograph published by American Psychiatric Publishing, Inc.