- Email: [email protected]
Re: Rief W, Sharpe M. Somatoform disorders. New approaches to classification, conceptualization, and treatment (Editorial). J Psychosom Res 2004; 56: 387–390
Journal of Psychosomatic Research 58 (2005) 211 – 212
Letter to the Editor Re: Rief W, Sharpe M. Somatoform disorders. New approaches to classification, conceptualization, and treatment (Editorial). J Psychosom Res 2004; 56: 387–390 Dear Editor: In their Editorial [1], Rief and Sharpe focused on the controversial problem of the classification of somatoform disorders (SD), reporting the issues of a debate among clinical scientists. They highlighted the several flaws of the current DSM-IV classification and suggested remarkable theoretical points for an alternative. Consistent with the authors of this and other recent editorials that have addressed the same problem in view of the preparation of the next DSM-V [2,3], a basic criticism can be expressed with regards to the two core concepts of SD. First, the diagnosis of SD is placed when somatic symptoms are likely to mimic brealQ symptoms of medical disease while not showing any evidence of it. The critical concept in this view is the distance considered as clinically excessive between the physical problem (inexistent or not being a plausible cause for actual symptoms) and the patient’s perception, thoughts, and behavior. Second, the somatic symptoms should not be secondary to other psychiatric disorders (mainly anxiety and depression), which have been often judged to be prominent over the somatoform symptoms. This view pertains to the concept of hierarchical organization, according to which, the somatoform symptoms are placed at the same level as other Axis I syndromes. A viable alternative could consider association instead of distance, and coexistence instead of hierarchy, namely, the psychological correlates of somatic symptom reporting, regardless of the presence of other psychiatric syndromes or the questionable distinction of functional illness versus physical disease [4,5]. Based on these theoretical guidelines, the Diagnostic Criteria for Psychosomatic Research (DCPR; [6]), developed by an international group of investigators, may represent a valuable instrument to assess and classify psychological conditions in the medically ill. The rationale for DCPR was that a wide body of evidence that has accumulated in psychosomatic medicine relating to concepts of quality of life, stressful life events, somatization, and personality disorders has not resulted in operational tools whereby the psychosocial aspects of medical diseases can be differentiated. Furthermore, the classic biomedical 0022-3999/04/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2004.09.008
paradigm involves a linear causal reasoning, according to which, if a psychological feature X is found to be significantly more prevalent in the medical disease baQ than in bbQ, then X is a characteristic of baQ. This model does not consider that psychological factors are unspecifically related to medical conditions that are instead heterogeneous and multidetermined. The DCPR approach focuses on psychological characteristics of patients presenting symptoms across different medical disorders. The DCPR classification includes 12 diagnostic categories for which operational criteria are provided. Four DCPR syndromes (alexithymia, Type A behavior, irritable mood, and demoralization) were conceived in addition to DSM categories and provide a better specification of the rubric of psychological factors affecting medical conditions. The other eight diagnostic criteria concern clinical phenomena related to the process of somatization and were developed as substitutes for or supplementary to the DSM categories of SD, i.e., disease phobia, thanatophobia, health anxiety, illness denial (which are various facets of the abnormal illness behavior), functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms, and anniversary reaction. Some clinical aspects concerning the use of the DCPR have been studied in detail. Applied to different groups of patients with a variety of clinical conditions, including functional gastrointestinal disorders (FGID; [7]), heart transplantation [8], myocardial infarction [9], endocrinological disorders [10], and cancer [11], the DCPR identified clinical and subthreshold psychological conditions in a proportion ranging from 2:1 to 3:1 compared with DSM-IV. Across medical disorders, 69% of patients fulfilling the DCPR criteria for demoralization did not satisfy the criteria for major depression, against 44% of patients with major depression who were not classified as demoralized. The DCPR can be assessed by means of a structured interview [12], and high sensitivity and specificity were found for diagnostic criteria such as alexithymia [13]. Furthermore, the clinical utility of the DCPR was also shown in predicting the treatment outcome of FGID patients [14]. As outlined by Rief and Sharpe in their editorial [1], and by other authors [2,3], the classification of SD still remains an open problem, and no easy solution is available. A better understanding of the somatization process can be achieved by investigating the role played by the psychological correlates
212
Letter to the Editor / Journal of Psychosomatic Research 58 (2005) 211 – 212
of physical disorders. Data seem to suggest that the DCPR can be helpful to that regard and easily used as an alternative or in conjunction with the official classification of the SD.
References [1] Rief W, Sharpe M. Somatoform disorders New approaches to classification, conceptualization, and treatment (Editorial). J Psychosom Res 2004;56:387 – 90. [2] Wise TN, Birket-Smith M. The somatoform disorders for DSM-V: the need for changes in process and content. Psychosomatics 2002; 43:437 – 40. [3] Mayou R, Levenson J, Sharpe M. Somatoform disorders in DSM-V. Psychosomatics 2003;44:449 – 51. [4] Fava GA, Mangelli L, Ruini C. Assessment of psychological distress in the setting of medical disease. Psychother Psychosom 2001;70: 171 – 5. [5] Fink P, Hansen MS, Oxhoj ML. The prevalence of somatoform disorders among internal medical inpatients. J Psychosom Res 2004; 56:413 – 8. [6] Fava GA, Freyberger HJ, Bech P, Christodoulou G, Sensky T, Theorell T, Wise TN. Diagnostic criteria for use in psychosomatic research. Psychother Psychosom 1995;63:1 – 8. [7] Porcelli P, De Carne M, Fava GA. Assessing somatization in functional gastrointestinal disorders: integration of different criteria. Psychother Psychosom 2000;69:198 – 204. [8] Grandi S, Fabbri S, Tossani E, Mangelli L, Branzi A, Magelli C. Psychological evaluation after cardiac transplantation: the integration of different criteria. Psychother Psychosom 2001;70:176 – 83. [9] Rafanelli C, Roncuzzi R, Finos L, Tossani E, Tomba E, Mangelli L, Urbinati S, Pinelli G, Fava GA. Psychological assessment in cardiac rehabilitation. Psychother Psychosom 2003;72:343 – 9.
[10] Sonino N, Navarrini C, Ruini C, Ottolini F, Paoletta A, Fallo F, Boscaro M, Fava GA. Persistent psychological distress in patients treated for endocrine disease. Psychother Psychosom 2004;73: 78 – 83. [11] Grassi L, Rossi E, Sabato S, Cruciani G, Zambelli M. Diagnostic Criteria for Psychosomatic Research (DCPR) and psychosocial variables in breast cancer patients. Psychosomatics [in press]. [12] Mangelli L, Rafanelli C, Porcelli P, Fava GA. Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR). Psychother Psychosom 2003;72:346 – 9. [13] Porcelli P, De Carne M. Criterion-related validity of the Diagnostic Criteria for Psychosomatic Research for alexithymia in patients with functional gastrointestinal disorders. Psychother Psychosom 2001; 70:184 – 8. [14] Porcelli P, De Carne M, Todarello O. The prediction of treatment outcome of patients with functional gastrointestinal disorders by the Diagnostic Criteria for Psychosomatic Research. Psychother Psychosom 2004;73:166 – 73.
Piero Porcelli Psychosomatic Unit IRCCS De Bellis Hospital Via Valente 4 70010 Castellana Grotte (Bari), Italy Tel.: +39 080 4960530 Fax: +39 080 4960273 E-mail address: [email protected] Lara Mangelli Department of Psychology University of Bologna, Italy
Letter to the Editor Re: Rief W, Sharpe M. Somatoform disorders. New approaches to classification, conceptualization, and treatment (Editorial). J Psychosom Res 2004; 56: 387–390 Dear Editor: In their Editorial [1], Rief and Sharpe focused on the controversial problem of the classification of somatoform disorders (SD), reporting the issues of a debate among clinical scientists. They highlighted the several flaws of the current DSM-IV classification and suggested remarkable theoretical points for an alternative. Consistent with the authors of this and other recent editorials that have addressed the same problem in view of the preparation of the next DSM-V [2,3], a basic criticism can be expressed with regards to the two core concepts of SD. First, the diagnosis of SD is placed when somatic symptoms are likely to mimic brealQ symptoms of medical disease while not showing any evidence of it. The critical concept in this view is the distance considered as clinically excessive between the physical problem (inexistent or not being a plausible cause for actual symptoms) and the patient’s perception, thoughts, and behavior. Second, the somatic symptoms should not be secondary to other psychiatric disorders (mainly anxiety and depression), which have been often judged to be prominent over the somatoform symptoms. This view pertains to the concept of hierarchical organization, according to which, the somatoform symptoms are placed at the same level as other Axis I syndromes. A viable alternative could consider association instead of distance, and coexistence instead of hierarchy, namely, the psychological correlates of somatic symptom reporting, regardless of the presence of other psychiatric syndromes or the questionable distinction of functional illness versus physical disease [4,5]. Based on these theoretical guidelines, the Diagnostic Criteria for Psychosomatic Research (DCPR; [6]), developed by an international group of investigators, may represent a valuable instrument to assess and classify psychological conditions in the medically ill. The rationale for DCPR was that a wide body of evidence that has accumulated in psychosomatic medicine relating to concepts of quality of life, stressful life events, somatization, and personality disorders has not resulted in operational tools whereby the psychosocial aspects of medical diseases can be differentiated. Furthermore, the classic biomedical 0022-3999/04/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2004.09.008
paradigm involves a linear causal reasoning, according to which, if a psychological feature X is found to be significantly more prevalent in the medical disease baQ than in bbQ, then X is a characteristic of baQ. This model does not consider that psychological factors are unspecifically related to medical conditions that are instead heterogeneous and multidetermined. The DCPR approach focuses on psychological characteristics of patients presenting symptoms across different medical disorders. The DCPR classification includes 12 diagnostic categories for which operational criteria are provided. Four DCPR syndromes (alexithymia, Type A behavior, irritable mood, and demoralization) were conceived in addition to DSM categories and provide a better specification of the rubric of psychological factors affecting medical conditions. The other eight diagnostic criteria concern clinical phenomena related to the process of somatization and were developed as substitutes for or supplementary to the DSM categories of SD, i.e., disease phobia, thanatophobia, health anxiety, illness denial (which are various facets of the abnormal illness behavior), functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms, and anniversary reaction. Some clinical aspects concerning the use of the DCPR have been studied in detail. Applied to different groups of patients with a variety of clinical conditions, including functional gastrointestinal disorders (FGID; [7]), heart transplantation [8], myocardial infarction [9], endocrinological disorders [10], and cancer [11], the DCPR identified clinical and subthreshold psychological conditions in a proportion ranging from 2:1 to 3:1 compared with DSM-IV. Across medical disorders, 69% of patients fulfilling the DCPR criteria for demoralization did not satisfy the criteria for major depression, against 44% of patients with major depression who were not classified as demoralized. The DCPR can be assessed by means of a structured interview [12], and high sensitivity and specificity were found for diagnostic criteria such as alexithymia [13]. Furthermore, the clinical utility of the DCPR was also shown in predicting the treatment outcome of FGID patients [14]. As outlined by Rief and Sharpe in their editorial [1], and by other authors [2,3], the classification of SD still remains an open problem, and no easy solution is available. A better understanding of the somatization process can be achieved by investigating the role played by the psychological correlates
212
Letter to the Editor / Journal of Psychosomatic Research 58 (2005) 211 – 212
of physical disorders. Data seem to suggest that the DCPR can be helpful to that regard and easily used as an alternative or in conjunction with the official classification of the SD.
References [1] Rief W, Sharpe M. Somatoform disorders New approaches to classification, conceptualization, and treatment (Editorial). J Psychosom Res 2004;56:387 – 90. [2] Wise TN, Birket-Smith M. The somatoform disorders for DSM-V: the need for changes in process and content. Psychosomatics 2002; 43:437 – 40. [3] Mayou R, Levenson J, Sharpe M. Somatoform disorders in DSM-V. Psychosomatics 2003;44:449 – 51. [4] Fava GA, Mangelli L, Ruini C. Assessment of psychological distress in the setting of medical disease. Psychother Psychosom 2001;70: 171 – 5. [5] Fink P, Hansen MS, Oxhoj ML. The prevalence of somatoform disorders among internal medical inpatients. J Psychosom Res 2004; 56:413 – 8. [6] Fava GA, Freyberger HJ, Bech P, Christodoulou G, Sensky T, Theorell T, Wise TN. Diagnostic criteria for use in psychosomatic research. Psychother Psychosom 1995;63:1 – 8. [7] Porcelli P, De Carne M, Fava GA. Assessing somatization in functional gastrointestinal disorders: integration of different criteria. Psychother Psychosom 2000;69:198 – 204. [8] Grandi S, Fabbri S, Tossani E, Mangelli L, Branzi A, Magelli C. Psychological evaluation after cardiac transplantation: the integration of different criteria. Psychother Psychosom 2001;70:176 – 83. [9] Rafanelli C, Roncuzzi R, Finos L, Tossani E, Tomba E, Mangelli L, Urbinati S, Pinelli G, Fava GA. Psychological assessment in cardiac rehabilitation. Psychother Psychosom 2003;72:343 – 9.
[10] Sonino N, Navarrini C, Ruini C, Ottolini F, Paoletta A, Fallo F, Boscaro M, Fava GA. Persistent psychological distress in patients treated for endocrine disease. Psychother Psychosom 2004;73: 78 – 83. [11] Grassi L, Rossi E, Sabato S, Cruciani G, Zambelli M. Diagnostic Criteria for Psychosomatic Research (DCPR) and psychosocial variables in breast cancer patients. Psychosomatics [in press]. [12] Mangelli L, Rafanelli C, Porcelli P, Fava GA. Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR). Psychother Psychosom 2003;72:346 – 9. [13] Porcelli P, De Carne M. Criterion-related validity of the Diagnostic Criteria for Psychosomatic Research for alexithymia in patients with functional gastrointestinal disorders. Psychother Psychosom 2001; 70:184 – 8. [14] Porcelli P, De Carne M, Todarello O. The prediction of treatment outcome of patients with functional gastrointestinal disorders by the Diagnostic Criteria for Psychosomatic Research. Psychother Psychosom 2004;73:166 – 73.
Piero Porcelli Psychosomatic Unit IRCCS De Bellis Hospital Via Valente 4 70010 Castellana Grotte (Bari), Italy Tel.: +39 080 4960530 Fax: +39 080 4960273 E-mail address: [email protected] Lara Mangelli Department of Psychology University of Bologna, Italy