Dr. Sharpe and Colleagues Reply

To the Editor:

Our article aimed to stimulate a debate. We are pleased that it has done so, both within these pages and outside them. We are encouraged that there has been so much support for a radical reconsideration of the terminology and classification of somatic symptoms that are apparently not fully “explained” by organic pathology.

We see little fundamental disagreement between Dr. Stein and ourselves. She is understandably concerned that we intend to give psychiatric diagnoses to the large number of patients who are seen in this way. We do not intend to do so. Indeed, we suggest just the opposite. Although such patients are currently eligible for a psychiatric diagnosis of somatoform disorder, we argue that in the future these somatic symptoms, which constitute a large part of medical practice and a small part of psychiatry, should be regarded as “medical.” Placing them on axis III of DSM does not mean that they are all being regarded as psychiatric; axis III is where DSM records medical diagnoses, such as diabetes. Of course, a minority of such patients will also satisfy criteria for a psychiatric DSM axis I disorder and may consequently be usefully regarded as having both a medical and a psychiatric diagnosis. Dr. Stein’s second main concern is that our suggestion of labeling such symptoms as “functional” implies that they have no biological basis. This concern is also misplaced. Indeed, we suggest the term “functional” in its original usage of a disturbance of functioning including that of the body (1) . Her third concern is about the heterogeneity of any category of functional symptoms. Again, we agree and argue that it should be subcategorized; indeed, in the article, we suggest a scheme for doing this. Perhaps our only point of disagreement with Dr. Stein is her proposal that somatization continues to be used in a psychodynamic sense; we believe that a descriptive system of classification remains the best approach.

Dr. Rief and colleagues disagree with our suggestion of abolishing the category of somatoform disorders. We appreciate our colleagues’ willingness to argue this case and look forward to continuing the debate with them. They propose that the category of somatoform disorders should be retained because it is a useful focus for mental health research. We are certainly in favor of more research into all aspects of symptoms, but we do not think that mental health researchers should have a monopoly. Indeed, we would point to examples of multidisciplinary research into irritable bowel syndrome as an example (2) . They also point out that the label of somatoform disorder is arguably less stigmatizing than previous diagnoses, such as hysteria. However, it is our view that it is not the precise label that is inappropriately stigmatizing but the fact that all persons with such somatic symptoms are given psychiatric diagnoses. They suggest that the existing medical functional syndrome diagnoses, such as irritable bowel syndrome, are inadequate and that they do not adequately capture the commonality of functional somatic syndromes (referenced in the letter by Dr. Rief et al.). We agree. However, we propose that this problem can be easily addressed by providing new axis III diagnoses, such as a multiple functional syndrome category (perhaps graded by severity). Dr. Rief et al. suggest that the existing category of somatoform disorders can be improved by tinkering with symptom lists and cutoff scores. However, we remain unconvinced that such tinkering will adequately address the substantial problems associated with the category. Finally, Dr. Rief et al. argue that we need greater understanding of the psychological aspects of functional symptoms and that our proposal would prevent that. We want to make it clear that we do not aim to remove consideration of psychological factors from functional somatic syndromes but rather to increase the importance given to psychological factors in relation to all somatic symptoms, not only those lacking an association with organic disease. An example is research into the importance of depression after myocardial infarction (3) . We argue that this more integrated approach will be facilitated if patients with medical diagnoses (whether “organic” or “functional”) in whom psychological factors are prominent receive both a medical axis III diagnosis and a psychiatric diagnosis (including the descriptor “psychological factors affecting medical condition”).

Our fundamental point is that greater progress is likely to be made if “mental health” and “medical” researchers collaborate on research into somatic symptoms. We regard our proposals as a first useful step toward the ultimate aim of integrating the currently separate medical and psychiatric classifications. Such a step only would not reduce confusion but would ultimately benefit doctors, researchers, and their patients.