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Psychological Factors Affecting Medical Condition: A New Proposal for DSM-V

The DSM category of “psychological factors affecting medical condition” had virtually no impact on clinical practice. However, several clinically relevant psychosomatic syndromes have been described in the literature: diseasephobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood. These syndromes, in addition to the DSM definition of hypochondriasis, can yield clinical specification in the category of “psychological factors affecting medical condition” and eliminate the need for the highly criticized DSM classification of somatoform disorders. This new classification issupported by a growing body of research evidence and is in line with psychosomatic medicine as a recognized subspecialty. (Psychosomatics 2007; 48:103–111)


ince its introduction in DSM-III, the classification of somatoform disorders has attracted considerable criticism. Because the section is organized by the common feature of physical symptoms that suggest a general-medical disorder, it may leadthe clinician to the false choice of deciding in a dichotomous manner whether the symptoms are based on an underlying medical condition or are due to the use of somatic terms as a proxy for psychosocial problems.1–5 Lipowski explained somatization as the tendency to experience and communicate psychological distress in the form of physical symptoms and to seek medical help for them but never ruledout the concurrence of an organic process.1 It is not surprising that many questions have arisen regarding this term. In particular, the DSM classification has performed poorly in primary-care and clinical samples, excluding a substantial proportion of patients displaying psychological distress and functional somatic symptoms.1–5 The DSM-IV workgroup for somatoform disorders also focused ondissociative, impulse control, and adjustment disorders. Many international investigators whose careers have focused on somatoform disorders were not part of the workgroup. Recently, Mayou et al.6 proposed that DSM-V abolish the diagnostic category of somatoform disorders and re-

distribute some of its current diagnoses into other groupings. Hypochondriasis should be renamed “health anxiety disorder”and grouped with body-dysmorphic disorder within anxiety disturbances. Somatization disorder would be defined as a combination of personality disorder (Axis II) and mood or anxiety disorders (Axis I). Somatic symptoms and syndromes and pain disorder would be classified on Axis III for reporting current general-medical conditions. Dissociative and conversion symptoms would remain separate.6 Inresponse to these suggestions, Hiller and Rief7 and Noyes et al.8 acknowledged that the classification of somatoform disorders lacks support in many areas and requires substantial modifications. However, they suggested that the diagnoses of hypochondriasis and somatization disorders have traditionally been recognized and are clinically distinct forms of somatic distress, each with prognostic andtherapeutic implications.7,8 Other suggestions for classifications of somatization have come from Fink et
From The Dept. of Psychology, Univ. of Bologna, Bologna, Italy. Send correspondence and reprint requests to G.A. Fava, M.D., Dept. of Psychology, Univ. of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. e-mail: Copyright 2007 The Academy of Psychosomatic MedicinePsychosomatics 48:2, March-April 2007


Psychological Factors and Medical Condition
al.,9 who elaborated a staging system for patients presenting with functional somatic symptoms in primary care, and Kroenke,10 who has proposed the new diagnostic category of Physical Symptom Disorder on Axis III, to replace somatization disorder, undifferentiated...
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