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A Reconceptualization of the Somatoform Disorders
RUSSELL NOYES JR., M.D. SCOTT P. STUART, M.D. DAVID B. WATSON, PH.D.

Since its introduction in DSM–III, the Somatoform Disorders category has been a subject of controversy. Critics of the grouping have claimed that it promotes dualism, assumes psychogenesis, and that it contains heterogeneous disorders that lack validity. The history of thesedisorders is one of shifting conceptualizations and disputes. A number of changes in the classification have been proposed, but few address problems that arise with the current formulation. The authors propose a dimensional reconceptualization based on marked and persistent somatic distress and care-eliciting behavior. This formulation is based on the interpersonal model of somatization. The authorspropose testing of this conceptualization and indicate how this might be done. (Psychosomatics 2008; 49:14–22)

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he framers of DSM–III took the “hysterical” and “hypochondriacal” neuroses from earlier versions and created a new category: the somatoform disorders.1–3 Many have regarded this new grouping as unsatisfactory and have offered various solutions to the problems they see, includingelimination of the category altogether.4 As the time for DSM–V approaches, debate about these disorders is intensifying, and impetus for change is growing.5–7 In this article, we review problems with the classification of somatoform disorders in DSM–IV, the background and development of this classification, and solutions proposed for DSM–V. We then offer a reconceptualization and suggest how this newmodel might be tested. Problems With the Current Classification Critics claim that the Somatoform Disorders section of DSM promotes mind–body dualism.8 Defined in terms of
Received February 6, 2007; accepted February 9, 2007. From the Dept. of Psychiatry, Carver College of Medicine, and the Dept. of Psychology, College of Liberal Arts and Sciences, Univ. of Iowa, IA City, IA. Send correspondence andreprint requests to Russell Noyes, M.D., Psychiatry Research, Medical Education Building., Univ. of Iowa, IA City, IA 52242-1000. e-mail: russell-noyes@uiowa.edu 2008 The Academy of Psychosomatic Medicine

physical symptoms, the somatoform disorders are regarded as psychological in nature because no organic disease explains them. Consistent with biomedical theory and practice, they are viewed asnon-legitimate disturbances for which patients themselves are responsible.9 Hence, patients with such disorders are seen as the province of psychiatry, rather than general medicine. Some claim that patients who are ill but without disease pose a threat to Western biomedicine.10 They say that, to maintain this system, it is necessary to devalue and stigmatize such patients.11 Although patients withpsychiatric disorders generally are stigmatized, those with somatoform disorders are singled out because these disorders masquerade as physical conditions.12 Critics contend that such disorders do not assume recognizable form in cultures lacking this dualism. They see them as creations of dualistic thinking.13 Somatoform Disorders in DSM–IV involve conceptual ambiguity.4 Individual disorders areconceptualized in terms not only of somatic distress but also an absence of organic disease and failure to respond to medical care. A diagnosis of hypochondriasis, for instance, requires a patient to have been evaluated by a physician, found to be

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Psychosomatics 49:1, January-February 2008

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without physical explanation for their symptoms, and to haveresisted appropriate reassurance.3 The somatoform disorder categories are criticized for lack of validity.14 Diagnostic categories are regarded as valid “if they have been shown to be discrete entities with natural boundaries that separate them from other disorders.”15 There have been few studies of clinical features, biological markers,16 family aggregation,17 longitudinal course, or treatment...