The psychogenic view generally considered somatic presentations as ancillary manifestations of psychological discomfort. The more direct and pragmatic approach to somatization that would eventually lead to the atheoretical frame of modern nomenclatures began with French psychopathologist Pierre Briquet,³ who, in 1859, brought an observational or experiential perspective to the study of hysteria during the golden age of French psychopathology. His description of a syndrome inclusive of multiple motor and sensorial symptoms (pseudoneurological symptoms) made possible the separation of somatization from conversion.

In the 1950s, a group of investigators at Washington University–Renard Hospital in St Louis resurrected Briquet’s concept of hysteria in several clinical studies. They formulated criteria for the diagnosis of hysteria that required the presence of a specified number of symptoms from a comprehensive list that included physical and psychological manifestations, personality traits, and behavioral expressions, in addition to the neurological symptoms from the traditional French definition.^4,5

With a few modifications, these were the criteria for somatization disorder proposed by Feighner and colleagues⁶ in 1972 in their seminal paper, “Diagnostic Criteria for Use in Psychiatric Research.” After Robert Spitzer and his colleagues⁷ coined the term “somatoform disorder” (inclusive of the Greek soma and the Latin form), it officially entered American and world psychiatric terminology with the publication of the International Classification of Diseases criteria in the late 1970s and the DSM-III in the 1980s.

Somatoform Disorders in DSM

Following the publication of DSM-III in the 1980s, somatization disorder (SD) became the key somatoform diagnosis. In DSM-III and its subsequent revisions, SD turned into a simple somatic symptom list that contracted or expanded rather capriciously. Partly because the atheoretical perspective of DSM discarded any presumptions of causality, other manifestations of the syndrome were not included in the criteria.

The list of somatoform disorders kept expanding with the addition of vague categories, such as “undifferentiated somatoform disorder” or “somatoform disorder NOS [not otherwise specified],” which, unfortunately, are the most common diagnoses within the somatoform genre. These terms failed to transcend specialty boundaries. Perhaps as a corollary of turf issues, general medicine and medical specialties started carving these syndromes with their own tools. The resulting list of “medicalized,” specialty-driven labels that continues to expand includes fibromyalgia, chronic fatigue syndome, multiple chemical sensitivity, and many others (Table 1).

Table 1 Functional somatic syndromes34 Irritable bowel syndrome Chronic fatigue syndrome Fibromyalgia Multiple chemical sensitivity Nonspecific chest pain Premenstrual disorder Non-ulcer dyspepsia Repetitive strain injury Tension headache Temporomandibular joint disorder Atypical facial pain Hyperventilation syndrome Globus syndrome Sick building syndrome Chronic pelvic pain Chronic whiplash syndrome   Chronic Lyme disease Silicone breast implant effects Candidiasis hypersensivity Food allergy Gulf War syndrome Mitral valve prolapse Hypoglycemia Chronic low back pain Dizziness Interstitial cystitis Tinnitus Pseudoseizures Insomnia Systemic yeast infection Total allergy syndrome

 

These labels fall under the general category of functional somatic syndromes and seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones. However, using DSM criteria, virtually all these functional syndromes would fall into the somatoform disorders category given their phenomenology, unknown physical causes, absence of reliable markers, and the frequent coexistence of somatic and psychiatric symptoms.