DSM-IV terms that could possibly replace the term: TMS

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There have been extensive and ongoing efforts to find a new name for the disorder that is referred to by a growing group of practitioners as "TMS." (An example can be found by clicking on this link.)

This article attempts to lay out a new nomenclature for TMS by building on terminology already in place in the "The Diagnostic and Statistical Manual of Mental Disorders (DSM)," of the American Psychiatric Association. By using terms that are already contained in the DSM, we can essentially sidestep the issue of gaining legitimacy for the term. Furthermore, it will become easier to use and contribute to existing literature.

The DSM-IV lists seven mental disorders under the main heading of Somataform Disorders, devoting a chapter to the category. These mental disorders are identified by the following traits:

• the presence of physical symptoms that suggest a medical condition but for which no medical cause can be found (this is where the term "somatoform" comes from)
• the symptoms cause clinically significant distress or impairment in social, occupation, or other important areas of functioning
• the symptoms are not intentionally produced or feigned (in contrast to Malingering" and Factitious Disorders)

The 7 somatoform disorders are summarised in the DSM-IV as follows:

Somatization Disorder (historically referred to as hysteria or Briquet's syndrome) is a polysymptomatic disorder that begins before age 30 years, extends over a period of years, and is characterized by a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms. Undifferentiated Somatoform Disorder is characterized by unexplained physical complaints, lasting at least 6 months, that are below the threshold for a diagnosis of Somatization Disorder. Conversion Disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be associated with the symptoms or deficits. Pain Disorder is characterized by pain as the predominant focus of clinical attention. In addition, psychological factors are judged to have an important role in its onset, severity, exacerbation, or maintenance. Hypochondriasis is the preoccupation with the fear of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms or bodily functions. Body Dysmorphic Disorder is the preoccupation with an imagined or exaggerated defect in physical appearance. Somatoform Disorder Not Otherwise Specified is included for coding disorders with somatoform symptoms that do not meet the criteria for any of the specific Somatoform Disorders.

Of the 7 diagnoses above, most TMS patients would be diagnosed with Pain Disorder. Many others would be diagnosed with "Somatization Disorder," "Undifferentiated Somatoform Disorder," "Conversion Disorder," or "Somatoform Disorder Not Otherwise Specified."

In general, the above diagnoses seem to capture TMS fairly well. Given this, the name for the overall category of disorders, "Somatoform Disorders," seems like a possible replacement for the term "TMS."

One possible problem with this is that if a patient's TMS is primarily associated with sexual function, they may be diagnosed with a Sexual Dysfunction such as Dyspareunia. Sexual dysfunctions are viewed as a separate category from Somatoform Disorders, but it is unlikely that anyone would object to considering Dyspareunia as a Somatoform disorder.

A second problem with this approach is that we would have 6 categories of TMS patients:

1. Somatization Disorder (if symptoms began before age 30 years, extend over a period of years, and include four pain symptoms, two gastrointestinal symptoms, one sexual symptom and one pseudoneurological symptom)
2. Undifferentiated Somatoform Disorder (if symptoms have persisted for more than 6 months and Pain Disorder is not more appropriate)
3. Conversion Disorder (if there are symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition and diagnostic criteria for Somatization Disorder are not met)
4. Pain Disorder (if pain is the predominant focus of clinical attention)
5. Dyspareunia or another Sexual Dysfunction (if the symptoms relate exclusively to sexual function)
6. Somatoform Disorder Not Otherwise Specified (if none of the other categories apply)

Two very large advantages gained by this approach would be the tremendous legitimacy conveyed by using DSM categories and the ability to more easily integrate our own research with preexisting research.

Each of the above disorders (except the sexual ones) are covered in their own section below:

Somatization Disorder (code: 300.81)

Somatization disorder has historically been referred to as hysteria or Briquet's syndrome. It is a polysymptomatic disorder that begins before age 30 years and extends over a period of years. The DSM-IV-TR criteria require that patients have at least four pain symptoms, two gastrointestinal symptoms, one sexual symptom and one pseudoneurological symptom when being diagnosed with Somatization Disorder. The gastrointestinal, sexual, and pseudoneurological symptoms must in some way go beyond pain. Given that most patients with TMS do not have all of these symptoms, somatization disorder probably won't make a great replacement for the term "TMS."

Details and examples as well as full diagnostic criteria can be found in the BehaveNet® Clinical Capsule™ on Somatization Disorder or in the relevant section of the free online copy of the DSM-IV.

Undifferentiated Somatoform Disorder (code: 300.82)

At first glance, undifferentiated Somatoform Disorder can be thought of as a less extreme version of Somatization Disorder. Unlike Somatoform Disorder, it need not have started before age 30 or have occurred over a period of "several years." Most notably, rather than requiring 8 symptoms from 4 different functional areas, it requires only "one or more physical complaints." According to the DSM-IV, the physical complaints most frequently associated with this disorder "are chronic fatigue, loss of appetite, or gastrointestinal or genitourinary symptoms." While this category could be used for many TMS patients, the most frequent complaint by TMS patients is pain, so Pain Disorder may make a better replacement for the term "TMS."

Details and examples as well as full diagnostic criteria can be found in the BehaveNet® Clinical Capsule™ on Undifferentiated Somatization Disorder or in the relevant section of the free online copy of the DSM-IV.

Conversion Disorder (code: 300.11)

Conversion disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function (i.e. paralysis or inability to sense pain, heat, cold, or other sensory stimulus) that suggest a neurological or other general medical condition. In conversion disorder, these symptoms or deficits are associated with the symptoms or deficits because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. Because most TMS patients don't have any problems with voluntary motor or sensory function, conversion disorder probably won't make a great replacement for the term "TMS."

Details and examples as well as full diagnostic criteria can be found in the BehaveNet® Clinical Capsule™ on Conversion Disorder or in the relevant section of the free online copy of the DSM-IV.

Pain Disorder (code: 307.80 or 307.89)

Pain Disorder has two subtypes, Pain Disorder Associated With Psychological Factors (code 307.80) and Pain Disorder Associated With Both Psychological Factors and a General Medical Condition (code 307.89). It is specified as Acute if the duration is less than 6 months and Chronic if the duration is greater than 6 months.

While many TMS patients will satisfy the diagnostic criteria of "Pain Disorder," many others will instead satisfy the criteria of the other Somatoform disorders, so it might be more helpful to use "Somatoform Disorder" as a replacement for the term "TMS" rather than using the term "Pain Disorder."

Because many TMS patients will satisfy the full diagnostic criteria for Pain Disorder, they are given below:

Diagnostic criteria for Pain Disorder (cautionary statement) A. Pain is in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. D. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering). E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia. Code as follows: 307.80 Pain Disorder Associated With Psychological Factors: psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This type of Pain Disorder is not diagnosed if criteria are also met for Somatization Disorder. 307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition: both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical site of the pain is coded on Axis III.

Details and examples as well as full diagnostic criteria can be found in the BehaveNet® Clinical Capsule™ on Pain Disorder or in the relevant section of the free online copy of the DSM-IV.

Somatoform Disorder Not Otherwise Specified

This designation (abbreviated NOS) can be used when the mental disorder appears to fall within the larger category of Somatoform Disorders, but does not meet the criteria of any specific disorder within the category. Most TMS patients will meet the criteria for one of the two Pain Disorders, so Somatoform Disorder NOS will not be relevant for them.

Details and examples can be found in the relevant section of the free online copy of the DSM-IV.

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