How is somatic symptom disorder diagnosed in the DSM-5?

Somatization disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder that were in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) have been removed in the new DSM-5. The DSM-IV diagnosis of somatization disorder required a specific number of complaints from among four symptom groups. This is not required in the criteria of somatic symptom disorder (SSD), but the physical complaints must cause significant distress, suffering, or they must disrupt daily functioning. In addition, they must be accompanied by excessive and disproportionate thoughts, feelings, or behaviors about these symptoms. To be diagnosed with SSD, the individual must experience symptoms continuously for at least 6 months.

Do somatic symptoms have to be medically unexplained?

Another important change in the DSM-5 criteria is that somatic symptoms do not have to be medically unexplained (as was the case in the DSM-IV). The explanation states that it is not justified to grant a person a mental disorder only when her/his complaints cannot be explained medically. In addition, whether the somatic symptoms can or cannot be explained, the individual must also meet the other criteria to receive a diagnosis of SSD. The DSM-5 criteria for SSD remove overlap and confusion that existed in the earlier editions. They encourage the clinician to provide comprehensive assessment of patients for accurate diagnosis and holistic care.

How has the DSM-5 improved diagnosis in general medical settings?

Most people with SSD are primarily seen in general medical settings. Therefore, the DSM-5 clarifies confusing terms and reduces the number of disorders and sub-categories to make the criteria more useful to non-psychiatric care providers. To ensure that the new criteria would indeed help clinicians better identify individuals who have SSD, scientists tested the SSD criteria in clinical practices during the DSM-5 field trials. The diagnostic reliability of the SSD performed very well. In the DSM-5, the emphasis is on the extent to which the patient has disproportionate or excessive thoughts, feelings, and behaviors about his or her somatic symptoms. The descriptive section on SSD notes that some patients with physical conditions, such as heart disease or cancer, may experience disproportionate and excessive thoughts, feelings, and behaviors related to their condition, and that these people therefore meet the criteria for SSD. 

How can the diagnostic ability of clinicians be improved?

To be able to recognize whether a patient's thoughts, feelings and behaviors indicate a psychological disorder that can improve with the help of focused treatment, requires clinical training, experience and judgment, based on guidance such as that contained in the DSM-5 text. This shift in emphasis removes the separation of body and mind, as is still implied in the DSM-IV. Clinicians are encouraged to make a comprehensive assessment and use clinical judgment rather than a checklist, that may arbitrarily disqualify people suffering from both SSD and another medical diagnosis from getting the help they need.

BulletPoint Summary

• The DSM-IV diagnosis of somatization disorder required a specific number of complaints from among four symptom groups. This is not required in the criteria of somatic symptom disorder (SSD) in the DSM-5, but the physical complaints must cause significant distress, suffering, or they must disrupt daily functioning. In addition, they must be accompanied by excessive and disproportionate thoughts, feelings, or behaviors about these symptoms.

• Somatic symptoms do no longer have to be medically unexplained in the DSM-5 diagnosis. It is noted that patients with physical conditions may have disproportionate or excessive thoughts, feelings and behaviors about these symptoms. The DSM-5 has also reduced the number of disorders and sub-categories, so that it is easier to use in non-psychiatric settings. This is especially important for people with SSD, because most of them are primarily seen in general medical settings.

• The diagnostic reliability of the SSD has performed very well.

• The writers encourage clinicians to not separate body from mind in their assessments and to use clinical judgment rather than a checklist.