The somatoform conundrum: a question of nosological values

This paper critically reviews the values and perspectives evident in the formulation of the category of Somatoform Disorders in the widely used Diagnostic and Statistical Manual-IV (DSM-IV) [1] of the American Psychiatric Association. The conflict of values evident in the DSM Committee's elimination of causal issues and including only descriptive criteria in the final classification is emphasized. In this approach, causation was dismissed and only a description of popular clinical entities was allowed. It becomes clear that there was a conflict between causal and descriptive factors in the formation of the current classifications. The dubious logic and the inconsistencies that underlie the linking of the various diagnoses under the Somatoform Disorder (SD) rubric is presented. A heuristic model of the interaction of psychological and somatic variables is described. These variables act in a causal fashion and should be the basis for any nosological system of the SDs. There is ample evidence to support the importance of causal factors in the development of SDs, and the current descriptive nomenclature does not do justice to the rapidly growing field of Psychosomatic Medicine. A new scheme is proposed, using the presence or absence of stress as the connecting link for the diagnoses offered. The old nosology enhances the perpetuation of the mind-body dichotomy. Stress, representing the way in which the environment impinges on the human being, allows the mind-body dichotomy to be eliminated. The preferred synthesis of mind-body interaction as partly the result of experience in the environment becomes the basis for the new nosology.