The clinical inadequacy of the DSM-5 classification of somatic symptom and related disorders: an alternative trans-diagnostic model.

The Diagnostic and Statistical of Mental Disorders, Fifth Edition (DSM-5) somatic symptom and related disorders chapter has a limited clinical utility. In addition to the problems that the single diagnostic rubrics and the deletion of the diagnosis of hypochondriasis entail, there are 2 major ambiguities: (1) the use of the term "somatic symptoms" reflects an ill-defined concept of somatization and (2) abnormal illness behavior is included in all diagnostic rubrics, but it is never conceptually defined. In the present review of the literature, we will attempt to approach the clinical issue from a different angle, by introducing the trans-diagnostic viewpoint of illness behavior and propose an alternative clinimetric classification system, based on the Diagnostic Criteria for Psychosomatic Research.

The classification of Obsessive-Compulsive and Related Disorders in the ICD-11.

BACKGROUND: To present the rationale for the new Obsessive-Compulsive and Related Disorders (OCRD) grouping in the Mental and Behavioural Disorders chapter of the Eleventh Revision of the World Health Organization's International Classification of Diseases and Related Health Problems (ICD-11), including the conceptualization and essential features of disorders in this grouping. METHODS: Review of the recommendations of the ICD-11 Working Group on the Classification for OCRD. These sought to maximize clinical utility, global applicability, and scientific validity. RESULTS: The rationale for the grouping is based on common clinical features of included disorders including repetitive unwanted thoughts and associated behaviours, and is supported by emerging evidence from imaging, neurochemical, and genetic studies. The proposed grouping includes obsessive-compulsive disorder, body dysmorphic disorder, hypochondriasis, olfactory reference disorder, and hoarding disorder. Body-focused repetitive behaviour disorders, including trichotillomania and excoriation disorder are also included. Tourette disorder, a neurological disorder in ICD-11, and personality disorder with anankastic features, a personality disorder in ICD-11, are recommended for cross-referencing. LIMITATIONS: Alternative nosological conceptualizations have been described in the literature and have some merit and empirical basis. Further work is needed to determine whether the proposed ICD-11 OCRD grouping and diagnostic guidelines are mostly likely to achieve the goals of maximizing clinical utility and global applicability. CONCLUSION: It is anticipated that creation of an OCRD grouping will contribute to accurate identification and appropriate treatment of affected patients as well as research efforts aimed at improving our understanding of the prevalence, assessment, and management of its constituent disorders.

Hypochondriasis: considerations for ICD-11.

The World Health Organization (WHO) is currently revisiting the ICD. In the 10th version of the ICD, approved in 1990, hypochondriacal symptoms are described in the context of both the primary condition hypochondriacal disorder and as secondary symptoms within a range of other mental disorders. Expansion of the research base since 1990 makes a critical evaluation and revision of both the definition and classification of hypochondriacal disorder timely. This article addresses the considerations reviewed by members of the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders in their proposal for the description and classification of hypochondriasis. The proposed revision emphasizes the phenomenological overlap with both anxiety disorders (e.g., fear, hypervigilance to bodily symptoms, and avoidance) and obsessive-compulsive and related disorders (e.g., preoccupation and repetitive behaviors) and the distinction from the somatoform disorders (presence of somatic symptom is not a critical characteristic). This revision aims to improve clinical utility by enabling better recognition and treatment of patients with hypochondriasis within the broad range of global health care settings.

Treatment of mental hypochondriasis: a case report.

Hypochondriasis is characterized by intensive fears of serious disease. Most patients with hypochondriasis worry about physical diseases like cancer, although in rare cases, patients report severe fears of mental disorders (e.g., schizophrenia), a phenomenon described in the literature as mental hypochondriasis. However, little is known about this rare subtype of hypochondriasis and experts have questioned whether mental hypochondriasis has much in common with the type of hypochondriasis in which somatic diseases are the focus of preoccupation. This paper presents, a case report of a woman with a fear of schizophrenia, which was treated with cognitive therapy. This patient fulfills the DSM-IV criteria of hypochondriasis and exhibits many characteristics (e.g., selective attention, safety behavior) considered to be maintaining factors in well-established cognitive-behavioral models of hypochondriasis. Cognitive treatment strategies for hypochondriasis (e.g., attention training, behavioral experiments) also proved effective in this case of mental hypochondriasis.

Hypochondriasis: considerations for ICD-11

The World Health Organization (WHO) is currently revisiting the ICD. In the 10th version of the ICD, approved in 1990, hypochondriacal symptoms are described in the context of both the primary condition hypochondriacal disorder and as secondary symptoms within a range of other mental disorders. Expansion of the research base since 1990 makes a critical evaluation and revision of both the definition and classification of hypochondriacal disorder timely. This article addresses the considerations reviewed by members of the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders in their proposal for the description and classification of hypochondriasis. The proposed revision emphasizes the phenomenological overlap with both anxiety disorders (e.g., fear, hypervigilance to bodily symptoms, and avoidance) and obsessive-compulsive and related disorders (e.g., preoccupation and repetitive behaviors) and the distinction from the somatoform disorders (presence of somatic symptom is not a critical characteristic). This revision aims to improve clinical utility by enabling better recognition and treatment of patients with hypochondriasis within the broad range of global health care settings.

[Effectiveness of psychopharmacotherapy of late hypochondriac depression].

Hypochondriac depression is typical for elderly people and is difficult to treat. An aim of the study was to estimate the effect of hypochondriac symptoms on the effectiveness of psychopharmacotherapy of late depression. It has been shown that psychopharmacotherapy of late depression with hypochondriac symptoms is significantly less effective than that of depression without such symptoms. Some predictors of psychopharmacotherapy effectiveness were identified. Many prognostically significant factors were consistent with those found earlier for late depression. The nosological attribution of depression without hypochondria to bipolar affective disorder may explain better effectiveness of its psychopharmacotherapy.

A taxometric study of hypochondriasis symptoms.

Hypochondriasis has been conceptualized as both a distinct category that is characterized by a disabling illness preoccupation and as a continuum of health concerns. Empirical support for one of these theoretical models will clarify inconsistent assessment approaches and study designs that have impeded theory and research. To facilitate progress, taxometric analyses were conducted to determine whether hypochondriasis is best understood as a discrete category, consistent with the DSM, or as a dimensional entity, consistent with prevailing opinion and most self-report measures. Data from a large undergraduate sample that completed 3 hypochondriasis symptom measures were factor analyzed. The 4 factor analytically derived symptom indicators were then used in these taxometric analyses. Consistent with our hypotheses and existing theory, results supported a dimensional structure for hypochondriasis. Implications for the conceptualization of hypochondriasis and directions for future study are discussed.

Health anxiety: current perspectives and future directions.

Health anxiety is a ubiquitous experience that arises when bodily sensations or changes are believed to be indicative of a serious disease. Severe expressions of health anxiety are most often classified as hypochondriasis in the current DSM-IV-TR; however, various alternative classification schemas have been proposed for the DSM-V. Regardless of classification, severe health anxiety has significant negative impacts on well-being, social and occupational functioning, and health care resource utilization. In this review, we focus on classification issues pertinent to severe health anxiety, summarize recent research regarding potential mechanisms underlying the condition, and summarize the state of the art with respect to assessment and treatment. Future research directions are noted and suggested throughout.

A reconceptualization of the somatoform disorders.

Since its introduction in DSM-III, the Somatoform Disorders category has been a subject of controversy. Critics of the grouping have claimed that it promotes dualism, assumes psychogenesis, and that it contains heterogeneous disorders that lack validity. The history of these disorders is one of shifting conceptualizations and disputes. A number of changes in the classification have been proposed, but few address problems that arise with the current formulation. The authors propose a dimensional reconceptualization based on marked and persistent somatic distress and care-eliciting behavior. This formulation is based on the interpersonal model of somatization. The authors propose testing of this conceptualization and indicate how this might be done.

New strategies in the assessment of psychological factors affecting medical conditions.

In this article, we examine research that may lead to a better assessment of psychological factors affecting medical conditions. We performed a review of the psychosomatic literature using both Medline and manual searches. We selected papers that were judged to be relevant to new strategies of assessment, with particular reference to the use of the Diagnostic Criteria for Psychosomatic Research. We assessed 8 areas concerned with the assessment of psychological factors in the setting of medical disease: hypochondriasis, disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, irritable mood, and Type A behavior. A new subclassification of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-V]; not yet published) category of psychological factors affecting physical conditions appears to be feasible and may provide the clinician with better tools for identifying psychological distress.

Psychological factors affecting medical condition: a new proposal for DSM-V.

The DSM category of "psychological factors affecting medical condition" had virtually no impact on clinical practice. However, several clinically relevant psychosomatic syndromes have been described in the literature: disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood. These syndromes, in addition to the DSM definition of hypochondriasis, can yield clinical specification in the category of "psychological factors affecting medical condition" and eliminate the need for the highly criticized DSM classification of somatoform disorders. This new classification is supported by a growing body of research evidence and is in line with psychosomatic medicine as a recognized subspecialty.

[...with psychotic features? An investigation into the delusional nature of convictions in patients with non-psychotic disorders]. / ...met psychotische kenmerken? Een onderzoek naar het waanachtige karakter van overtuigingen buiten het psychosencluster.

BACKGROUND: In certain disorders the boundaries between thoughts, obsessions, overvalued ideas and delusions are not always clearly delineated. AIM: To find out whether delusions can be distinguished from the convictions that often accompany anorexia nervosa, obsessive compulsive disorder (OCD), body dysmorphic disorder (BDD) and hypochondriasis, all of which apparently may involve impaired reality testing. METHOD: The literature was reviewed with the help of PubMed, using as key words 'delusions' in combination with 'hypochodriasis', 'anorexia nervosa', 'body image', 'obsessive compulsive disorder' or 'body dysmorphic disorder'. We also searched the Tijdschrift voor Psychiatrie and references of the literature we used. RESULTS: A number of disorders can probably be classified on a spectrum ranging from non-psychotic to psychotic. For instance, OCD, hypochondriasis, BDD and to a lesser degree anorexia nervosa can all be particularized as 'with good insight', 'with poor insight' or 'with psychotic features'. CONCLUSION: Current practice in DSM-IV is to classify OCD, BDD or hypochondriasis and a delusional disorder as separate entities; this way of classifying seems to be an artefact. Our findings indicate that a dimensional system of classifying psychotic systems is preferable to a categorised system.

[Hypochondria circumscripta (to the problem of coenesthesiopathic paranoia)].

Hypochondria circumscripta manifests in patients with paranoial personality and signs of somatopsychic accentuation. A sample included 11 patients (6 men, 5 women, mean age 54 years) who referred to dermatologists or had been admitted to gastroenterological and psychiatric units. Pathokinesis of hypochondria circumscripta comprises three stages: idiopathic algias, overmastering sensations and possession of pain. In the latter stage, delusional behavior targeted to the elimination of a part of the body, which is perceived as the source of pain, develops. Psychopathological disorders are realized in limits of coenesthesiopathic spectrum without tendency to interpretive delusion manifestation as well as transformation to systematic delusion of persecution during the disease course. As a consequence of above mentioned peculiarities of psychopathological structure, the stage of possession of pain may be designated as coenesthesiopathic paranoia. Because of the small sample, the findings can be considered as preliminary ones.

The boundary between hypochondriasis and obsessive-compulsive disorder: a cross-sectional study from the Netherlands.

OBJECTIVE: To investigate similarities and differences between the symptom profiles of patients with hypochondriasis and those of patients with obsessive-compulsive disorder (OCD) and to compare the contamination/cleaning OCD subtype to other OCD subtypes. METHOD: Between January 1998 and July 2002, 76 patients diagnosed with hypochondriasis (N = 31) or OCD (N = 45) (DSM-IV criteria) and 25 subjects with no formal DSM-IV diagnosis were compared with regard to the extent of diagnosis-specific symptoms, the number and nature of physical symptoms, and whether these symptoms evoked fear. The analyses were repeated after subdividing the OCD patients into the contamination/cleaning and other OCD subgroups. RESULTS: Patients with hypochondriasis and OCD differed significantly from each other on the extent of diagnosis-specific symptoms (all p < .001). Patients with hypochondriasis reported significantly more obsessive-compulsive symptoms and patients with OCD reported significantly more hypochondriacal symptoms than did the healthy control-group members (all p < .05). Neither group differed significantly from the other on the number and nature of feared physical symptoms. The contamination/cleaning OCD subtype did not differ significantly from other OCD subtypes in either the severity of hypochondriacal symptoms or the number of feared physical symptoms. CONCLUSION: Hypochondriasis and OCD can be distinguished on the basis of diagnosis-specific symptoms, although they share a number of similarities. In addition, although patients with the contamination/cleaning OCD subtype tend to be afraid of contracting diseases, the differences between the symptom profiles of these patients and those of patients with hypochondriasis exceed the similarities. Our results confirm that the 2 conditions are separable and valid diagnoses.

Clinical pictures and classification of somatoform disorders in dermatology.

Somatoform disorders in dermatology are a heterogeneous group from a biopsychosocial point of view. Among the clinical patterns we find, for example, pruritus, pain, paresthesia as well as feelings of disfiguration, eco-syndromes, erythrophobia or psychogenic pseudoeffluvium. The multiple clinical symptoms are usually accompanied by psychosocial disorders, these are subjective complaints by the patient which cannot be medically objectified. The relevant somatoform disorders in dermatology can be differentiated as somatisation disorders, hypochondriacal disorders, somatoform autonomous disorders, persistent somatoform pain disorders and "other somatoform disorders". A precise differential-diagnostic division is necessary in order to initiate adequate therapy strategies. With this overview article, we would like to make an updated classification recommendation for dermatology and present experiences in therapy.