RSS Feeds
Rethinking Somatization
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TO THE EDITOR:
I enjoyed McWhinney and colleagues' article on rethinking somatization [1]. The authors allude to the inadequacy of classifying such syndromes as fibromyalgia, the chronic fatigue syndrome, and functional bowel disorders as undifferentiated somatoform disorders in the Diagnosis and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
Recent advances in our understanding of pain mechanisms should lead to reclassifying these conditions as disorders characterized by chronic pain amplification. Yunus [2] has proposed labeling the overlapping symptoms and signs of fibromyalgia, the chronic fatigue syndrome, functional bowel disorders, irritable bladder, and tension headache as components of a dysfunctional spectrum syndrome (DSS) [2]. Controlled studies have shown that patients with DSS have elevated cerebrospinal fluid levels of substance P, excitatory amino acids, and a relative serotonin deficiency [3, 4]. These abnormalities augment nociceptive responses and produce allodynia. Allodynia is a clinical situation in which pain results from a stimulus that should not normally be painful. Fibromyalgia, for example, is a form of chronic, widespread allodynia. Functional bowel disorders (nonulcer dyspepsia, noncardiac chest pain, spastic colitis, and chronic abdominal pain) are not consequences of dysmotility but examples of autonomically mediated visceral hyperalgesia [5].
Unfortunately, DSM-IV classifies pain disorders as those associated with a general medical condition or those caused by psychological factors. It fails to include evidence that acute and chronic pain have different pathways and pathophysiologic mechanisms. Patients with DSS have a normal response to acute pain. Chronic amplified pain perception results in the behavioral constructs and physiologic symptoms associated with DSS.
Nevertheless, the psychological management of DSS will never progress until mental health professionals shed DSS from the somatoform disorder category. A new DSM-V listing under “Pain Disorders,” which deals with behavioral and biological alterations to chronic pain perception, should be created.
Daniel J. Wallace, MD
Cedars-Sinai Medical Center; Los Angeles, CA 90048
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
