Evolution of bodily distress disorders.

PURPOSE OF REVIEW: The nomenclature and classification of somatoform disorders have undergone revisions in the fifth edition of the Diagnostic and Statistical Manual (DSM 5) and the upcoming eleventh edition of the International Classification of Diseases (ICD-11). The present review describes the changes that have evolved and highlight the possible challenges. RECENT FINDINGS: Bodily distress disorders replace the term somatoform disorders. The emphasis on the symptoms to be medically unexplained has been removed. The need to have a certain number of symptoms associated with different organ systems has made way to the presence of one or more distressing bodily symptoms. The focus on psychological aspects like excessive attention, thoughts, and behaviors associated with bodily symptoms have been added to make it a more diagnosis of inclusion rather than exclusion. An additional qualifier of severity has been added, which highlights the importance of impairment associated with these symptoms. SUMMARY: The diagnostic criteria for bodily distress disorders is a step towards making the diagnostic criteria clinically useful and appears to be applicable across the healthcare settings. However, the ability to discern this diagnosis with the newly revised classification of chronic pain and the possibility of over psychologizing the medical disorders need to be researched.

Functional somatic disorders: discussion paper for a new common classification for research and clinical use.

BACKGROUND: Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs. MAIN BODY: We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrum - and also within organ system-specific chapters of a classification - they should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD). CONCLUSION: We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.

Functional gait disorders, clinical phenomenology, and classification.

BACKGROUND: Functional gait disorders (FGDs) are relatively common in patients presenting for evaluation of a functional movement disorder (FMD). The diagnosis and classification of FGDs is complex because patients may have a primary FGD or a FMD interfering with gait. METHODS: We performed a detailed evaluation of clinical information and video recordings of gait in patients diagnosed with FMDs. RESULTS: We studied a total of 153 patients with FMDs, 68% females, with a mean age at onset of 36.4 years. A primary FGD was observed in 39.2% of patients; among these patients, 13 (8.5%) had an isolated FGD (a gait disorder without other FMDs). FMDs presented in 34% of patients with otherwise normal gait. Tremor was the most common FMD appearing during gait, but dystonia was the most common FMD interfering with gait. Patients with FGD had a higher frequency of slow-hesitant gait, astasia-abasia, bouncing, wide-based gait and scissoring compared with patients with FMDs occurring during gait. Bouncing gait with knee buckling was more frequently observed in patients with isolated FGD (P = 0.017). Patients with FGDs had a trend for higher frequency of wheelchair dependency (P = 0.073) than those with FMDs interfering with gait. CONCLUSIONS: Abnormal gait may be observed as a primary FGD or in patients with other FMDs appearing during gait; both conditions are common and may cause disability.

Identifying subgroups based on self-management skills in primary care patients with moderate medically unexplained physical symptoms.

OBJECTIVE: Medically Unexplained Physical Symptoms (MUPS) are a major burden on both patients and society and frequently develop into chronic MUPS. Self-management interventions may prevent moderate MUPS from becoming chronic. Tailoring interventions to the patient population is strongly recommended. This can be facilitated by identifying subgroups based on self-management skills. This study aimed to identify these subgroups and their clinical profiles in primary care patients with moderate MUPS. METHODS: A cross-sectional study was performed on baseline measurements from a randomized clinical trial (PARASOL-study). To identify subgroups based on self-management skills, a hierarchical cluster analysis was conducted for adults with moderate MUPS from primary health care centers. Self-management skills were measured with the Health education impact Questionnaire. Cluster variables were seven constructs of this questionnaire. Additionally, specific patient profiles were determined by comparing the identified clusters on the clinical variables pain, fatigue and physical functioning. RESULTS: Four subgroups were identified: High-Self-Management Skills (SMS) (n = 29), Medium-SMS (n = 55), Low-SMS (n = 49) and Active & Low Distress-SMS (n = 20). The latter showed a distinctly different pattern on cluster variables, while the other subgroups differed significantly on means of the cluster variables (p < .001). On clinical variables, significant differences between subgroups were mainly found on fatigue and physical functioning. CONCLUSION: This study found four specific subgroups based on self-management skills in moderate MUPS-patients. One subgroup demonstrated a distinctly different pattern on self-management skills. In other subgroups, more similar patterns on self-management skills were found that negatively correlated with pain and fatigue and positively correlated with physical functioning.

Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?

Objective: Disorders characterized by "distressing unexplained somatic symptoms" are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample. Methodology: As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed. Results: The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with "being a BSS" case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72). Conclusion: Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

What Has Happened to Hysteria?

This article traces the history of the diagnosis of hysteria from the earliest medical formulations in the 17th century to the present, including the presence of this diagnosis in the five iterations of the Diagnostic Statistical Manual (DSM) of the American Psychiatric Association. Several different types of hysteria are discussed, with alternative causal explanations. Research focusing on this disorder is summarized.

Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?

OBJECTIVE: Disorders characterized by "distressing unexplained somatic symptoms" are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample. METHODOLOGY: As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed. RESULTS: The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with "being a BSS" case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72). CONCLUSION: Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

The Influence of Trauma on Autobiographical Memory in the Assessment of Somatoform Disorders According to DSM IV Criteria.

Recalling an event impairs an individual's later ability to recall related knowledge. Impairment in this retrieval-induced forgetting (RIF) produces a dysfunction in autobiographical memory. This, like somatic symptoms, has been documented in trauma and sexual abuse survivors. To investigate the relationship between past trauma and somatoform disorders, and the role of memory recall dysfunction in this relationship, three sex-matched groups were constituted using DSM IV criteria: Somatoform (SD) (n. 22) other Psychiatric Disorders (PD) (n. 26) and Healthy Subjects (HS) (n. 35). Responses to Stressful Life Events Screening Questionnaire revised (SLESQ-R); Direct Forgetting paradigm (DF) for autobiographical memory; Deese-Roediger-McDermott (DRM) paradigm for false memory; Stanford Scale type A for Post-Hypnotic Amnesia (PHA); Stroop Colour Word test and a digit-span for cognitive assessment; and Somatosensory Amplification Scale (SSAS), Somatic Dissociation Questionnaire (SDQ-20), and Toronto Alexithymia Scale (TAS 20) for somatic discomfort were compared among groups. SSAS, SDQ-20 and TAS F1 were correlated with SLESQ-R scores; subjects with higher numbers of traumatic events (NSE) showed greater capacity to remember items-to-be-forgotten (DFF) and higher SDQ-20 scores. Although the SD group showed higher NSE, their autobiographical memory scores were no different to those of other DSM-IV groups. The somatic-trauma-autobiographical memory impairment relationship is identified by DSM V but not DSM IV criteria for somatoform disorder. Higher NSE appears to correlate with both the presence of somatic discomfort and impaired autobiographical memory, suggesting autonoetic consciousness dysfunction in subjects with past trauma and current somatic symptom disorders.

Ecofenotipos en la depresión mayor: el papel del maltrato físico en la infancia / Ecophenotypes in major depression: the role of child physical abuse

La depresión mayor puede derivarse de distintos factores de riesgo, entre los cuales se han destacado las experiencias de adversidad a lo largo de los años de desarrollo. En la presente investigación, nos preguntamos si la experiencia de maltrato físico, uno de los factores de riesgo documentados, se asocia a características clínicas diferenciales en los pacientes con depresión mayor. En el estudio, con un diseño transversal, comparamos dos grupos de pacientes que cumplían criterios diagnósticos DSM-IV para depresión mayor. El primer grupo estaba formado por 20 pacientes que refirieron maltrato físico en la infancia y el segundo, por otros 52 pacientes que no refirieron maltrato físico u otras formas de maltrato. Los resultados indican características clínicas diferenciales. En concreto, el maltrato se asocia a una mayor frecuencia de episodios depresivos previos al actual, a mayor intensidad de la sintomatología depresiva, tendencia a la autodevaluación, conducta suicida a lo largo de la vida, rasgos disfuncionales de la personalidad, funcionamiento académico/laboral más afectado, disfunciones cognitivas sutiles, paranoidismo y dificultades en la interacción social. Se discuten las posibles vías a través de las cuales la adversidad en la infancia puede ejercer su impacto en este ecofenotipo clínico, así como algunas implicaciones terapéuticas

Major depression can be derived from different risk factors, among which experiences of adversity throughout the years of development have been highlighted. In the present work, we investigated whether the experience of physical abuse, one of the documented risk factors, is associated with distinct clinical characteristics among patients with major depression. In the study, with a cross-sectional design, we compared two groups of patients with major depression according to DSM-IV. One group consisted of 20 patients who reported child physical abuse and the other consisted of 52 patients who did not report child physical abuse or other forms of child abuse. Our results showed differential clinical features. In particular, child physical abuse was associated with a higher number of previous depressive episodes, higher levels of depressive symptoms, self-deprecation, suicidal behavior throughout the life span, dysfunctional personality traits, impaired academic/work performance, subtle cognitive dysfunctions, paranoidism, and difficulties in social relationships. The pathways through which childhood adversity may have an impact on this clinical ecophenotype and some therapeutic implications are discussed

A qualitative study on psychopathology of dhat syndrome in men: Implications for classification of disorders.

BACKGROUND: Dhat syndrome is regarded by many as a culture bound syndrome of the Indian sub-continent. However the nosological status, conceptual understanding of the condition as well as the diagnostic guidelines are all mired in controversy. AIMS: The current study aims to study the psychopathology of Dhat syndrome in men by using a qualitative approach and to arrive at an operational definition for diagnosing Dhat syndrome. METHOD: The qualitative approach consisted of five Focus Group Discussions (FGD) and five Key Individual Interviews (KII) with participants, consisting of patients as well as doctors - both allopathic as well as traditional. RESULTS: Detailed analysis revealed valuable data regarding the symptoms, causes, treatment measures, socio-cultural context, psychiatric co-morbidity, nature of the disorder and various other phenomenological dimensions. Ideas for future nosological positioning were also specifically looked for. Operational definition and diagnostic guidelines were also arrived at based on the analysis as well as on previous literature. CONCLUSION: Although lot of agreement existed among various stakeholders about symptoms and presentation, they varied significantly in their opinion on nature of the condition and treatment. Suggestions for ICD 11 have been made.

Gender similarities in somatic depression and in DSM depression secondary symptom profiles within the context of severity and bereavement.

BACKGROUND: Most population studies report higher rates of depression among women than men, and some researchers have observed gender differences in depression symptoms overall, or in sub-groupings (e.g. somatic depression). However, gender symptom differences have been inconsistent, prompting this investigation of gender differences in secondary DSM symptom profiles in the context of bereavement status, age, and depression severity. METHODS: Individuals with symptoms of core depression (flat affect or anhedonia) were selected from a large survey of adults in the Alberta, Canada workforce. Analyses involved the comparison of gender profiles across the seven DSM-IV secondary depressive symptoms plus a MANOVA of sex, bereavement, and age, with secondary symptoms comprising the dependent variable. RESULTS: Gender profiles were very similar, irrespective of depression severity or bereavement. Secondary symptoms were marginally more common among women and more frequent among bereaved young adults, but there was no evidence for a gender-related somatic factor. LIMITATIONS: First, data were gathered only for persons in the workforce and thus may not be generalizable to, for example, stay-at-home parents or those with employment issues. Second, the focus here is restricted to DSM symptoms, leaving risk factors, social roles, and brain functioning for separate investigation. Third, inferences were drawn from associations between groups of persons, rather than between individuals, requiring caution when speculating about individual attributes. CONCLUSIONS: Gender differences in depression represent a difference in amount, not kind, suggesting that the range of depressive experiences is similar for men and women. There was no gender difference ascribable to somatic depression.

Psychogenic itch.

Psychogenic itch can be defined as "an itch disorder where itch is at the center of the symptomatology and where psychological factors play an evident role in the triggering, intensity, aggravation, or persistence of the pruritus." The disorder is poorly known by both psychiatrists and dermatologists and this review summarizes data on psychogenic itch. Because differential diagnosis is difficult, the frequency is poorly known. The burden is huge for people suffering from this disorder but a management associating psychological and pharmacological approach could be very helpful. Classification, psychopathology, and physiopathology are still debating. New data from brain imaging could be very helpful. Psychological factors are known to modulate itch in all patients, but there is a specific diagnosis of psychogenic itch that must be proposed cautiously. Neurophysiological and psychological theories are not mutually exclusive and can be used to better understand this disorder. Itch can be mentally induced. Opioids and other neurotransmitters, such as acetylcholine and dopamine, are probably involved in this phenomenon.

Comparison of patients diagnosed with "complex pain" and "somatoform pain".

BACKGROUND AND AIM: Chronic pain conditions can be diagnosed and treated in both somatic and psychiatric settings. It is still a discussed and unanswered question whether the two groups of patients differ. The purpose of this short article is to inform further reflections concerning the classifications of somatoform pain and complex pain. METHOD: Sociodemographic and questionnaire data concerning anxiety and depression, perceived injustice, well-being, and levels of psycho-physiological functioning were compared for patients diagnosed with complex pain (somatic diagnosis) at a pain clinic and somatoform pain (psychiatric diagnosis) at a Liaison-psychiatric clinic. RESULTS: Very little differences were found between patients with complex pain (N=162) and somatoform conditions (N=89). Both patient groups were seriously impaired both physically and mentally. CONCLUSION: These comparisons lend support to the viewpoint of non-segregation of somatoform and complex pain. IMPLICATIONS: Pain treatment might be better-managed in common multidisciplinary centers with specialists in both pain treatment and psychiatric aid.

Core Outcome Domains for Clinical Trials on Somatic Symptom Disorder, Bodily Distress Disorder, and Functional Somatic Syndromes: European Network on Somatic Symptom Disorders Recommendations.

OBJECTIVE: The harmonization of core outcome domains in clinical trials facilitates comparison and pooling of data, and simplifies the preparation and review of research projects and comparison of risks and benefits of treatments. Therefore, we provide recommendations for the core outcome domains that should be considered in clinical trials on the efficacy and effectiveness of interventions for somatic symptom disorder, bodily distress disorder, and functional somatic syndromes. METHODS: The European Network on Somatic Symptom Disorders group of more than 20 experts in the field met twice in Hamburg to discuss issues of assessment and intervention research in somatic symptom disorder, bodily distress disorder, and functional somatic syndromes. The consensus meetings identified core outcome domains that should be considered in clinical trials evaluating treatments for somatic symptom disorder and associated functional somatic syndromes. RESULTS: The following core domains should be considered when defining ascertainment methods in clinical trials: a) classification of somatic symptom disorder/bodily distress disorder, associated functional somatic syndromes, and comorbid mental disorders (using structured clinical interviews), duration of symptoms, medical morbidity, and prior treatments; b) location, intensity, and interference of somatic symptoms; c) associated psychobehavioral features and biological markers; d) illness consequences (quality of life, disability, health care utilization, health care costs; e) global improvement and treatment satisfaction; and f) unwanted negative effects. CONCLUSIONS: The proposed criteria are intended to improve synergies of clinical trials and to facilitate decision making when comparing different treatment approaches. These recommendations should not result in inflexible guidelines, but increase consistency across investigations in this field.

Somatoform symptoms profiles in relation to psychological disorders - A population classification analysis in a large sample of general adults.

In order to identifying somatoform symptoms profiles, classifying study population and evaluating of psychological disorders in extracted classes, we carried out a cross-sectional study on 4762 Iranian adults. Somatoform symptoms were assessed using a comprehensive 30-items questionnaire and psychological disorders were evaluated by 12-item General Health Questionnaire (GHQ-12) and Hospital Anxiety and Depression Scale (HADS) questionnaires. Factor analysis and factor mixture modeling (FMM) were used for data analysis. Four somatoform symptoms profiles were extracted, including 'psycho-fatigue', 'gastrointestinal', 'neuro- skeletal' and 'pharyngeal-respiratory'. According to FMM results, a two-class four-factor structure, based somatoform symptoms, was identified in our study population. Two identified classes were labeled as "low psycho-fatigue complaints" and "high psycho-fatigue complaints". The scores of psychological disorders profile was significantly associated with four somatoform symptoms profiles in both classes; however the stronger relationship was observed in high psycho-fatigue complaints class. The prevalence of all the somatoform symptoms among participants assigned to the "high psycho-fatigue complaints" class was significantly higher than other class. We concluded that somatoform symptoms have a dimensional-categorical structure within our study population. Our study also provided informative pathways on the association of psychological disorders with somatoform symptoms. These findings could be useful for dealing with treatment's approaches.

Patterns of 'Abnormal' Illness Behavior among Healthy Individuals.

OBJECTIVES: We extend the seminal work of Professor Issy Pilowsky by presenting a contemporary re-conceptualization of abnormal illness behavior (AIB) as a general psychological phenomenon evident among healthy community members. METHODS: Participants (N = 344) completed a self- report questionnaire comprising health information and well-validated psychological measures from the field of somatization (eg, AIB, attributional style for physical symptoms, cognitive distortion of somatic information, illness likelihood, maladaptive coping). RESULTS: Cluster analysis of illness behavior responses resulted in 3 unique groupings distinguished by key health and psychological variables. Cluster 1 reflected 'normal' responses, Cluster 2 'atypical' and Cluster 3 'maladaptive'. Cluster 3 may represent a personality attribute indicative of a general style of interpreting illness in a more extreme way (trait AIB) whereas Cluster 2 may reflect a transient response to a specific illness event (state AIB). CONCLUSIONS: The construct of 'abnormal' illness behavior may usefully be extended to include individual differences in responses regardless of current health status. Furthermore, the potential to further characterize illness behavior as either dispositional (trait) or situational (state) emerges as a fruitful area for future analyses. Specifically, longitudinal studies are recommended to determine the causal links between health events and illness behavior profiles.

Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders.

BACKGROUND: DSM-5 introduced a fundamental revision of the category of somatoform disorders, which resulted in the new somatic symptom disorder (SSD) and related disorders. However, prognostic validity of SSD remains unclear, while other classification proposals, such as bodily distress disorder (BDD) or polysymptomatic distress disorder (PSDD), might be promising alternatives for the new ICD-11. Therefore, the comparison of the different approaches concerning long-term prognosis of disorder-relevant factors is of special interest. METHOD: In a longitudinal design (baseline, 1-year, and 4-year follow-up), the three proposals (SSD, BDD, PSDD) were compared in an age-representative sample of the German general population (N = 321). To this end, the baseline sample was divided into three independent pairs of groups (with/without SSD, with/without BDD, with/without PSDD). It was tested how well each approach differentiated with regard to medium- and long-term healthcare utilization, number of symptoms, and impairment. RESULTS: Criteria for BDD distinguished best with regard to future healthcare utilization resulting in a large-sized effect (f = 0.44) for the difference between persons with and without BDD, while SSD and PSDD revealed only medium-sized effects (f = 0.28 and f = 0.32) between subjects with and without diagnosis. The three proposals distinguished equally well with regard to future subjective impairment (between f = 0.39 and f = 0.41) and the number of reported symptoms (between f = 0.77 and f = 0.83). CONCLUSION: In accordance with our data regarding prognostic validity, the current draft of the WHO group is based on the BDD proposal. However, existing limitations and weaknesses of the present proposal for the ICD-11 are further discussed.

"Medically unexplained" symptoms and symptom disorders in primary care: prognosis-based recognition and classification.

BACKGROUND: Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called "medically unexplained symptoms" (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions. DISCUSSION: We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient's risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors. CONCLUSION: Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.