To examine analytically the question of whether the characterization of somatoform disorders (SFDs) in Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) provides adequate grounds for classifying them as mental disorders rather than as physical disorders.
Several recent articles [1], [2], [3], [4] and [5] have commented on the need to rethink the category of somatoform disorders (SFDs) and on the need to investigate the conceptual as well as the empirical questions involved. This paper investigates a key conceptual issue that has received little attention so far: Does the characterization of SFDs in Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) of the American Psychiatric Association (APA) provide adequate grounds for classifying SFDs as mental disorders?
Sometimes, attempts are made to brush this question aside as an inappropriate one. Sometimes, it is said that we should not ask whether a disorder is a physical or mental one: We should merely ask what the physical, psychological, or mental aspects of a disorder are and should refuse to answer the question as to whether the disorder is a physical or mental one.
In many situations, this may be a reasonable response. However, in the context of a classification system, such as DSM-IV, this response is not appropriate. The disorders that DSM-IV classifies are expressly said to be mental disorders, and it is a legitimate question to ask whether the disorders that DSM-IV lists as mental disorders are appropriately so listed or whether it would be more appropriate to list them as physical disorders, or, in the language of DSM-IV, as general medical conditions.
The question of whether a disorder should be classified as a physical or a mental one is not simply an academic issue. It is a question that is particularly important for patients for it can have significant, practical consequences for them. It is likely to influence how they will be treated, who will treat them, and whether they will have to cope with the many disadvantages of a mental illness label, such as financial and employment disadvantages, as well as stigma [6]. Further, a mental illness label, when inappropriately applied, may lead to the unjustified attribution of psychological problems that patients do not have, the exaggeration of psychological problems that they do have, and the neglect of any physical problems that are present. It may also lead to discord in the doctor–patient relationship and to less-than-optimal treatment [6].
It is well established that patients with medically unexplained symptoms commonly have mental disorders such as anxiety and depression and that these disorders are often not diagnosed and treated [7]. However, it is also important to realize that there is a corresponding (yet opposite) problem—patients with medically unexplained symptoms are frequently credited with mental disorders or psychological problems for which there is little real evidence, and this causes serious difficulties. What is needed is an accurate evaluation that neither underestimates nor overestimates the physical and mental problems involved. A good classification system can help achieve this result.
