Special Mini-Series on Somatoform Disorders Guest editors: Kurt Kroenke and Michael SharpeBodily symptoms: New approaches to classification
Introduction
Most of the previous psychiatric literature on how best to conceptualize medically unexplained bodily symptoms has considered this issue separately from that of medically explained symptoms. We argue that there is a need to address the larger problem of how we conceptualize all bodily symptoms.
Patients commonly present to doctors with bodily symptoms. Doctors seek to understand these by making a diagnosis. A medical diagnosis may be made, defined in terms of bodily pathology (e.g., cancer or infection), and the symptom is then regarded as “medically explained.” When no bodily pathology is found, a psychiatric diagnosis may be made, defined in terms of psychopathology, and the symptom is regarded as being “medically unexplained” [1]. Thus, symptoms are conceived of as being attributable to either bodily pathology or psychopathology. These conceptualizations of bodily symptoms are based on three closely related assumptions:
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Disease pathology “explains” bodily symptoms.
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Bodily symptoms not explained by disease pathology are explained by “psychopathology.”
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It is clinically useful to classify “unexplained” bodily symptoms as “psychiatric” and explained symptoms as medical.
In this short position paper, we (a) briefly examine each of these assumptions; (b) consider the potential implications of challenging these assumptions for diagnostic classifications, both psychiatric and medical; (c) suggest requirements for an ideal system of classification; and (d) propose two new ways of classifying bodily symptoms based on these requirements.
Section snippets
Does disease pathology explain bodily symptoms?
It is commonly assumed that bodily symptoms reflect bodily pathology, but is this always the case? If a patient feels pain in his or her leg and examination and investigation reveal that the tibia is fractured, then a doctor is likely to conclude that the fractured tibia explains the pain. While this seems obvious, the evidence suggests that such a simple causal relationship between pathology and pain does not always occur. First, patients may have bodily pathology without having symptoms: a
Are bodily symptoms that are not explained by pathology explained by psychopathology?
When patients have bodily symptoms, with no identifiable bodily pathology, it is often assumed that the symptom is psychological in origin; that is, it is explained by psychopathology that is expressed via somatisation, which is a process wherein it is proposed that psychopathology is somehow transformed into bodily symptoms [7]. However, the evidence suggests that this explanation does not always apply. First, although patients with medically unexplained bodily symptoms often present with
Is it clinically useful to classify unexplained bodily symptoms as psychiatric and explained symptoms as medical?
Whatever the scientific arguments about validity, one may argue that there is practical utility [12] in regarding those symptoms explained by bodily pathology as medical and those not so explained as psychiatric. This distinction is widely accepted in medical and lay opinion and is also reflected in the current official diagnostic classifications such as ICD and DSM. Hence, the ICD classification of medical diagnoses based on disease pathology is useful in highlighting targets for
Alternative approaches to the conceptualization and diagnosis of bodily symptoms
We therefore argue that it is necessary to consider bodily symptoms in their own right, not just as manifestations of either bodily pathology or psychopathology. Furthermore, the evidence favors a more complex conceptualization of etiology that includes social, psychological, and biological–etiological factors in all cases [18]. This more integrated approach is consistent with both the biopsychosocial model as proposed by Engel [19] and with our emergent understanding of bodily symptoms as
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