Canadian
Psychiatric Association
Perspectives Article
Somatic Symptom Disorder, Medically
Unexplained Symptoms, Somatoform
Disorders, Functional Neurological
Disorder: How DSM-5 Got It Wrong
Anton Scamvougeras, MBChB, FRCPC1 ,
and Andrew Howard, MD, FRCPC1
Keywords
somatoform disorders, somatic symptom disorder, functional neurological disorder, medically unexplained symptoms,
somatization, DSM-5, conversion disorder
“Truth is the daughter of time, not of authority.”
Francis Bacon
One in five individuals seeking primary medical care in any
part of the world complains of physical symptoms which,
after very thorough assessment and investigation, cannot be
found to be caused by any identifiable general medical con-
dition.1,2 The way in which these patients are understood,
and their conditions classified, shapes the treatment they are
offered, the course of their symptoms, and their future qual-
ity of life.
There is a very long history of medicine and psychiatry
working to develop an understanding of conditions charac-
terized by “medically unexplained symptoms” (MUS).3,4,5
Largely by virtue of historical medical discipline subdivi-
sion, these symptoms have been separated into two groups:
those suggestive of neurological disease (such as weakness,
convulsions, or disturbance of vision) and those suggestive
of nonneurological disease (such as gastrointestinal distur-
bance, pain, or fatigue). There are theoretical and empirical
reasons for suggesting that the two groups be collapsed into
one, as many patients with these conditions develop both
neurological and nonneurological symptoms.6,7
Unexplained neurological symptoms retain classification
that is partly true to their nature under the American Psy-
chiatric Association’s DSM-5. 8 Conversion disorder
remains, gaining the new co-title functional neurological
symptom disorder. Here, the clinician still has to judge that
symptoms are “medically unexplained” in deeming that
“clinical findings provide evidence of incompatibility
between the symptom and recognized neurological or med-
ical conditions.” 8 There is, however, no longer the need to
determine that “psychological factors are judged to be
Association des psychiatres
du Canada
The Canadian Journal of Psychiatry /
La Revue Canadienne de Psychiatrie
2020, Vol. 65(5) 301-305
ª The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0706743720912858
TheCJP.ca | LaRCP.ca
associated” (as was the case in DSM-IV), a change that we
believe to be in essence incorrect.
Unexplained nonneurological symptoms are abandoned
as a distinct group by DSM-5 and are dealt with in a new and
fundamentally different fashion. They are “lumped in” with
conditions where demonstrable general medical conditions
cause excessive emotion, behavior, or cognitions in the
patient. This change represents an important and unfortunate
error, one that is destined to mislead clinicians and research-
ers in the field for the foreseeable future. Under DSM-5,
most patients with this group of symptoms will not receive
the type of clinical approach that gives them the best chance
of positive outcomes, and our understanding of the field will
not advance as well as it could.
DSM-IV Needed Improvement
DSM-III had done away with the term “hysteria” in relation
to these conditions, a welcome step.9 DSM-IV, published in
1994, described somatoform disorders as a group of syn-
dromes that had in common the “presence of physical symp-
toms that suggest a general medical condition” that were
“not fully explained by a general medical condition.”10
Despite the face validity and clinical experience supporting
this group of disorders, the way DSM-IV dealt with
1
UBC Neuropsychiatry Program, Department of Psychiatry, University of
British Columbia, Vancouver, British Columbia, Canada
Corresponding Author:
Anton Scamvougeras, MD, FRCPC, UBC Neuropsychiatry Program, UBC
Department of Psychiatry, Detwiller Pavilion, 2255 Wesbrook Mall,
Vancouver, British Columbia, Canada V6T 2A1.
Email: anton.scamvougeras@ubc.ca
302
somatoform conditions muddied the waters. For example,
there were significant threshold and sensitivity problems
with the major subdivisions. In a study looking at 119
patients in family practitioners’ waiting rooms, somatization
disorder criteria were met in just one patient, while 94 met
criteria for undifferentiated somatoform disorder.11 Thus,
criteria were too tight for one diagnostic entity and too loose
for the other, with neither serving as a useful instrument for
separating the majority of individuals with significant soma-
toform symptoms from the general population. There was
also an unclear basis for separating the syndromes, as similar
sets of symptoms could exist across many of the defined
diagnoses. DSM-IV did not promote a valid or clinically
useful understanding of somatoform concepts, and it dis-
couraged clinicians from identifying these disorders. A
2009 survey of physicians revealed that DSM-IV definitions
of somatoform disorders and its subgroups were unclear to
many.12 Not surprisingly, clinicians simply didn’t use the
classification system and, although known to have high pre-
valence, these disorders were severely underdiagnosed.13
There was clearly room for improvement.
DSM-5 Abandons Nonneurological MUS
DSM-5 “reconceptualized” somatoform disorders,14 chang-
ing the category name to somatic symptom and related dis-
orders, a group of disorders all characterized by the presence
of physical symptoms. The most profound change was the
creation of a newly defined core disorder, somatic symptom
disorder (SSD), a syndrome characterized by persistent and
clinically significant somatic complaints accompanied by
excessive and disproportionate health-related thoughts, feel-
ings, and behaviors regarding the physical symptoms.
Patients who met DSM-IV criteria for a nonneurological
somatoform condition would almost all currently meet SSD
criteria. Further, SSD now includes most individuals previ-
ously diagnosed with hypochondriasis.8 In addition, and cru-
cially, SSD now includes individuals with demonstrable
physical disease with “excessive thoughts, feelings, or
behaviors” about their physical symptoms. Thus, SSD
groups together patients with demonstrable peripheral
pathology and those with no such pathology.
The DSM-5 Working Group, 10 specialists in the field,
worked on the changes from 2000 until publication of DSM-
5 in 2013. Through these years, the classification of these
disorders was much debated in the literature. The main areas
of discussion were the wisdom of using MUS as part of the
criteria, the validity of subdivisions, and the nomenclature.
Some argued for a fundamental change in the cate-
gory 15,16,17,18 ; others for essentially retaining the
“somatoform” concept while making other refine-
ments.19,20,21,22 The Working Group shared their reasons for
the fundamental changes, both during the development pro-
cess,23 and on publication of DSM-5.14 In response to
appeals for input, the authors shared a critique of the
intended changes in a letter to the Working Group in 2011.24
The Canadian Journal of Psychiatry 65(5)
The DSM-5 Rationale for the Eradication of
“MUS” as a Central Idea for
Nonneurological Symptoms and Signs
Let us consider the reasons given for this fundamental change,
and some counterarguments:
The reliability of assessing whether or not there is an explana-
tion for somatic symptoms is notoriously poor.14
On the contrary, after a thorough clinical assessment, includ-
ing special investigations as necessary, a clinician can draw the
conclusion that symptoms are medically unexplained with a
similar degree of certainty as one would have in making the
diagnosis in many general medical conditions and other psy-
chiatric diagnoses.25,26 Furthermore, any limitations in diagnos-
tic precision need to be weighed against the risks of not making
a diagnosis where one may reasonably be made, and the con-
sequent risk of potentially treatable syndromes going untreated.
Some MUS are not so much “Unexplained” as “Unexamined.”14
This is a criticism of incomplete assessment, not specific
to MUS. This same criticism could be made regarding
approaches to any other psychiatric or general medical con-
dition. A thorough assessment is always essential.
A diagnosis built upon a foundation of MUS is perilous because
it reinforces mind/body dualism.14
It is thereby argued that to say that physical symptoms are
“medically unexplained” may lead some patients and clin-
icians to conclude that the mind and body are distinct and
separable, and, presumably, that the symptoms may be due
to some “nonphysical” process. This dualistic thinking is
incorrect. All neuropsychiatric conditions are mediated by
brain function. All aspects of somatoform conditions are
products of complex brain function and dysfunction, the
specific nature of which we do not yet understand. It is vital
that we address the challenge presented by any tendency to
dualistic thinking directly. The answer is not to abandon the
concept of somatoform conditions out of fear that some may
misunderstand but rather to wrestle with the challenge, to
engage the field in discussion, and to educate clinicians and
patients about the nature of these conditions. They do indeed
involve complex interactions between what most of us
would consider to be the mind and the body. But all of these
interactions are manifestations of various levels of physio-
logical function and dysfunction. Indeed, a thorough under-
standing of the somatoform process serves as an integrative
force and proves supportive to arguments against dualism.
. . . the MUS approach is not well accepted by patients who feel
that MUS implies that their symptoms are inauthentic and “all in
your head.” This is a poor basis for a therapeutic alliance with
patients who are suffering distressing somatic complaints.14
La Revue Canadienne de Psychiatrie 65(5)
A similar challenge exists when helping all individuals
suffering other psychiatric and psychological conditions.
This challenge is partly related to the stigma regarding men-
tal illness that persists in our society and partly due to the
complex emotions (including fear, puzzlement, guilt, anger)
that an individual may experience when they have the
thought that something may be awry with their mind. The
only way forward is to understand these conditions for what
they are and, on the foundation of thorough assessment and
empathic therapeutic alliance, to help those suffering from
them. A clinician should, in a supportive fashion, share the
truth about the condition with the patient. These disorders
are, indeed, all mediated by brain function and dysfunction,
so they are indeed literally based in large part “in one’s
head”; however, from a figurative perspective, they are not
“imagined,” so this distinction must be made clear for the
patient. The unconscious and involuntary nature of the pro-
cess must be emphasized, and the nature of the condition
plainly described. To avoid the truth because it may be
unpalatable does not serve patients well at all, as optimal
management is predicated on a valid understanding of the
disorder. It is also poor science.
It bases a diagnosis on a negative . . . .23
. . . a medical diagnosis does not usually define a disorder
based on the absence of something.14
Clinicians go through a logical process of elimination
whenever they consider the differential diagnosis for any set
of symptoms and signs. Exclusion of known diseases is part
of every diagnostic process. If, at the end of such a process,
the clinical picture suggests MUS, then they should be called
that. That judgment is not qualitatively very different from
what we are doing with many other disease entities. It is
further implied that making the diagnosis of a MUS is some-
how a “negative” step in a broader sense, in that clinicians
and patients see it as the “taking away” of something rather
than a “positive” diagnosis. Many diagnoses in general med-
icine embrace the fact that there are unknown components to
the pathogenesis. For instance, after ruling out hypertension
secondary to renal, endocrine, or other general medical con-
ditions, the hypertension is labeled “idiopathic.” Patients
don’t complain that they have lost something or had some-
thing “taken away” in that process. We would argue that
making a somatoform disorder diagnosis is as proactive a
diagnostic step as the making of any other diagnosis, and we
believe that we in the field should work to actively frame it
as such. The patient should be informed that their syndrome
is the result of complex brain processes, not demonstrable
brain or peripheral tissue pathology. This has positive impli-
cations for treatment, and we should help the patient under-
stand that. Indeed, we would suggest that it is the clinician’s
duty to make such judgments and to offer to treat the patient
accordingly. It is only with such a judgment call that the
disorder can be understood, and appropriate management
instituted.
303
The DSM-5 Rationale for the Change in
Nomenclature From “Somatoform
Disorders” to “Somatic Symptom and
Related Disorders”
With the move away from MUS, it is not surprising that DSM-5
moved away from the “somatoform” label. Nonetheless, an
additional set of reasons was offered for removing the term,
namely, it “has been difficult to understand,” it was “a neolo-
gism, blending Latin and Greek,” and because it was “often
confused with somatization disorder.” 14 Various terms have
been suggested as the best label to refer to the group of condi-
tions based on MUS, including “functional,” “psychogenic,”
“psychosomatic,” “psychophysiological,” “bodily distress,”
“somatic,” “somatization,” and “somatoform.” “Somatoform”
is precisely the word that most elegantly captures the essence of
these conditions. It suggests a condition that is “in the form of”
the body while simultaneously implying that there is more to it
than that. The fact that “somatoform” is a Greek–Latin hybrid
puts it in the good company of many other hybrid medical
terms including “neuroscience,” “neurotransmitter,” and
“hypertension.”27 “Somatoform” has no more potential for
being confused with “somatization” than does “somatic
symptom.” This is a matter of educating clinicians and patients
and being clear and consistent in our use of the term. “Somatic
symptom disorder” is arguably a confusing term because on the
face of it, it could easily be misunderstood to describe any
disorder that involves a physical (“somatic”) symptom. In this
sense, it is potentially hobbled by its breadth and lack of inher-
ent specificity, as was “pain disorder” in DSM-IV.
Core Concerns and Implications
Overall, DSM-5 argues that the core problems with DSM-IV
somatoform disorders were based on confusing nomenclature,
and numerous untenable problems relating to identifying
MUS. However, the problem with DSM-IV was not the
“somatoform” name, nor the concept itself, but rather the fact
that the classification system did not promote a clear under-
standing of somatoform conditions, and the main disorders did
not identify and separate out patients with somatoform disor-
ders in a clinically useful or valid fashion. Thus, the system was
hardly used, and under it, the majority of individuals with
somatoform disorders were not identified or assisted.
Empirical evidence and clinical experience still supports
the idea of somatoform disorders as a valid diagnostic entity,
embracing both neurological and nonneurological symptom
types. Granted, a small percentage of these patients may be
suffering rare or as yet unidentified medical conditions, and
all patients with medically unexplained physical symptoms
require very thorough ongoing monitoring for the possible
emergence of physical disease. But there is strong evidence
that the vast majority do not have peripheral tissue pathology
but are suffering the results of direct or indirect expression of
underlying emotional distress, through the process referred
to as “somatization.” Evidence for the validity of the
304
somatization process includes but is not limited to: the non-
physiological patterns of symptoms or signs (they do not
follow the patterns seen in well-described diseases); the pat-
terns of symptoms based on patient beliefs; the atypical
course of the condition; the high rates of association of these
symptoms with overt emotional distress; the many persua-
sive clinical examples of “conversion” of mental distress
into physical syndromes; the longitudinal natural history of
these conditions (with only very small percentages revealing
some other causative underlying tissue pathology over time);
and the positive responses to psychological and psychiatric
therapies when a somatization model is assumed.
The crucial flaw in the approach of DSM-5 is around the
clinician’s judgment regarding MUS. DSM-5 and others are
advocating for “acceptance of etiological neutrality about those
symptoms that are not clearly associated with a general medical
condition.” 17 One can see the attraction of the apparent logical
rigor and prudence suggested by the DSM-5 approach: How can
we ever be sure that there is not some as-yet-unidentified med-
ical condition causing the symptoms and signs? And, as we
can’t be certain, let us rather withhold judgment. But diagnoses
in complex neurobehavioral conditions are seldom made with
certainty. In making judgment calls about MUS and the nature
of somatoform disorders, the clinician has to weigh the risk of
error in diagnosis against the risk of not making a diagnosis
where one can reasonably be made. The latter risks include
potentially treatable illnesses not being treated.
Figure. Diagram demonstrating the differences between DSM-5
somatic symptom disorder and the recommended somatoform
disorders classification. The authors maintain that it is valid and
advisable to make the division between “nonneurological psycho-
genic symptoms and signs” and “general medical conditions with
excessive affect, behaviors, (and/or) cognitions.”
There is a more robust and straightforward approach to
understanding and classifying these conditions, as some
have suggested.20,21,28,29 The idea and label of “somatoform
disorders” should be resurrected. A somatoform disorder
should be diagnosed in any clinical situation where physical
The Canadian Journal of Psychiatry 65(5)
symptoms and signs are judged, after thorough assessment,
to be the result of underlying emotional distress rather than
primary physical disease. The disorder can then be further
characterized by listing the psychogenic physical symptoms
and signs, and giving an account of the nature of the under-
lying dysphoria (be it a psychiatric syndrome and/or related
to psychological factors and stressors).29
This understanding naturally leads to the planning of
effective management for the majority of patients, an
approach that addresses physical MUS as well as underlying
dysphoria. Management is readily customized to the specific
needs of each patient and can also take advantage of the
specific skill set of the treating clinician. 29 Using this
approach, prognosis is often surprisingly good and largely
depends on the prognosis of the cause of the underlying
dysphoria.30
Authors’ Note
Anton Scamvougeras and Andrew Howard are neuropsychiatrists
in the University of British Columbia Neuropsychiatry Program,
UBC Department of Psychiatry, Vancouver, BC. Their book
Understanding and Managing Somatoform Disorders—A Guide for
Clinicians was published in 2018 and reviewed in the Canadian
Journal of Psychiatry by François Mai in 2019.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Anton Scamvougeras, MBChB, FRCPC https://orcid.org/0000-
0001-8543-3670
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