DSM IV criteria for clinical consideration, by Colleen Perry

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Colleen Perry, MFT

The following are categories under the title Somatoform Disorders from the DSM-IV

300.81 Somatization Disorder

A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

B. Each of the following criteria must have been met, with individual symptoms

occurring at any time during the course of the disturbance:

(1) four pain symptoms

(2) two gastrointestinal symptoms

(3) one sexual symptom

(4) one pseudoneurological symptom

C. Either (1) or (2):

(1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance

(2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings

D. The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).

Obviously, not all of our patients will meet the exact requirements under B.

Then there is 300.82 Undifferentiated Somatoform Disorder which is one or more physical complaints, either (1) or (2) from above, symptoms cause significant clinical distress, duration at least 6 months, disturbance not better accounted for by another mental disorder (which includes another somatoform disorder, which I'll be getting to) and D from above. In my opinion, this is not the best overall diagnosis for us to work with.

300.11 Conversion Disorder

1. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
2. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.
3. The symptom or deficit is not intentionally produced or feigned
4. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.
5. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
6. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

This may be what rules this out for our purposes. There are specifiers to this one:

With motor symptom or deficit

With sensory symptom or deficit

With seizures or convulsions

With mixed presentation

Here is the one that many of us seem to be using already:

Pain Disorder

1. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
2. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
4. The symptom or deficit is not intentionally produced or feigned
5. 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. Etc….

Specify if:

Acute: duration of less than 6 months

Chronic: duration of 6 months or longer

Then there is 307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition . It seems we all agree that this diagnosis would “muddy the waters” for our patients and be a barrier to them accepting their pain as psychological in nature.

I'm not sure how much luck we will have at getting something like Mindbody Syndrome, or TMS, or Stress Induced Illness, etc into the DSM when this diagnosis already exists as Pain Disorder Associated with Psychological Factors. That's a mouthful! What about PDPF since acronyms seem to be the marketing trend? It's not as warm and inviting as Mindbody Syndrome though, but neither is TMS. However, TMS is highly recognizable to those already in the community, but not to the population at large. It seems to me that this is where our challenge lies.

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