LETTER
Rethinking Somatization
Daniel J. Wallace, MD
15 December 1997 | Volume 127 Issue 12 | Page 1132
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.
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Author and Article Information
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Cedars-Sinai Medical Center; Los Angeles, CA 90048
1. McWhinney IR, Epstein RM, Freeman TR. Rethinking somatization. Ann Intern Med. 1997; 126:747-50.
2. Yunus MB. Fibromyalgia syndrome: clinical features and spectrum. J Musculoskel Pain. 1994; 2:5-21.
3. Wallace D. The fibromyalgia syndrome. Ann Med. 1997; 29:9-21.
4. Russell IJ, Orr MD, Littman B, Vipraio GA, Alboukrek D, Michalek JE, et al. Elevated cerebrospinal fluid levels of substance P in patients with fibromyalgia syndrome. Arthritis Rheum. 1994; 37:1593-601.
5. Mayer EA. Clinical implications of visceral hyperalgesia. Contemp Intern Med. 1994; 6:42-54.
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