The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill
Abstract
This new condition suggested in the bible of mental health diagnoses lacks specificity, says Allen Frances
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Emerging themes in the revision of the classification of somatoform disorders
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“Critics argue that a large percentage of seriously physically ill individuals are anxious enough about their condition to meet criteria for having maladaptive thoughts and feelings and thus qualify for psychiatric diagnosis (Frances 2013).”
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“After publication, SSD criteria were criticized as imprecise (Mayou, 2014) and overinclu-sive, risking overdiagnosis (Frances, 2013).”
BackgroundMethodChronic pain, psychopathology, and DSM-5 Somatic Symptom Disorder
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“Terms such as psychosomatic, ‘medically unexplained’, somatisation and somatoform seem to beg more questions than answers, and have lost their clinical and scientific utility [172], resulting in significant recent debate surrounding new classifications [5,173].”
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“From the point of view of somatic medicine, the inconsistency of the category ‘excessive thoughts, feelings and behaviors’ and the risk of mislabelling people with somatic diseases as mentally ill have been highlighted (King, 2013).”
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“As the diagnosis no longer excludes patients with a somatic disease, it is argued that many people with medical conditions will now be mislabeled as mentally ill [13].”
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“3 (25) 8 (0) 10 (1) 6 (1) 2 (48) 6 (1) 7 (3) 2 (20) 4 (2) 6 (0)”
Häuser, W., Bialas, P., Welsch, K., & Wolfe, F. (2015) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2015.03.151 · Cited by 61 · see citing works
“Concerns about the over-inclusive criteria of SSD[37], which risks to mislabeling people as mentally ill, has been raised patients with major medical diseases [41,42].”
BackgroundFeltz-Cornelis, C. M. V. D., Elfeddali, I., Werneke, U., Malt, U. F., den Bergh, O. V., Schaefert, R., Kop, W. J., Lobo, A., Sharpe, M., Söllner, W., et al. (2018) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2018.00151 · Cited by 52 · see citing works
“This in its own right poses new diagnostic and treatment challenges (22, 23).”
BackgroundVoigt, K., Wollburg, E., Weinmann, N., Herzog, A., Meyer, B., Langs, G., & Löwe, B. (2013) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2013.08.017 · Cited by 42 · see citing works
“Considering that a large number of symptoms and unclear etiology of symptoms are no longer required as diagnostic criteria, we would also argue that it now seems all the more vital to specify diagnostic criteria that are defined with precision and empirically validated in order to protect the new diagnosis against cri…”
BackgroundWhy Bioethics Should Be Concerned With Medically Unexplained Symptoms
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“Though the DSM-5 replaced somatoform disorders with “somatic symptom disorders” in 2013, that decision was made over the intense and very public objections of many in mental health (Carney 2012; Frances 2013; Hickey 2014), and patient advocacy (Bernhard 2012; Edwards 2013; Richards 2013).”
BackgroundBehm, A. C., Hüsing, P., Löwe, B., & Toussaint, A. C. (2021) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2021.152265 · Cited by 34 · see citing works
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“Besides potential bias due to recall, this result may also add to the argument on the SSD diagnosis as being too liberal, resulting in overinclusive and heterogeneous groups of patients (8).”
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DSM-5 somatic symptom disorder in patients with vertigo and dizziness symptoms
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“On the other hand, SSD was criticized most importantly for being over-inclusive by throwing together several diagnoses into one for the sake of clinical utility (Frances, 2013; Rief, 2013).”
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“This proposition is supported by recent opinions suggesting that the DSM-V somatic symptom diagnostic criteria are so inclusive that they increase the risk of healthy patients being classi fi ed as mentally ill (Frances, 2013).”
DSM-5 Somatic Symptom Disorder
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“With the DSM-5, patients worried about having a medical illness will often be diagnosed with somatic symptom disorder (5), normal grief will be misidentified as major depressive disorder, the forgetfulness of old age will be confused with mild neurocognitive disorder, temper tantrums will be labeled disruptive mood dy…”
Operationalization of diagnostic criteria of DSM-5 somatic symptom disorders
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“” Concerns were raised that, if handled improperly, a vast group of people might be mislabeled with mental disorders [3].”
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“Although members of the DSM-5 workgroup for somatic symptom disorders insist that this change encourages comprehensive assessment of patients for accurate diagnoses and holistic care [9], some authors, on the other hand, have stated their concerns as these new criteria's may be problematic in terms of misdiagnosis [10…”
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“The comparatively low prevalence of SSD in our survey could also be an indication that the new diagnosis according to DSM-5 would not lead to an overestimation of SSD, as has already been considered [12,41].”
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“It was listed as a criterion for a cluster of diagnoses (somatoform disorders) in the fourth edition of DSM, but was intentionally excluded from the fifth edition, published in 2013 (see American Psychiatric Association, 2013; for criticism see Frances, 2013).”
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“…literature and levelled two major criticisms against the DSM-5: (a) field testing was inadequate (Frances and Widiger 2012), and (b) there was a high probability of misdiagnosing a medical condition (including pain) as a mental illness (Frances & Widiger, 2012; Frances, 2013; Hauser & Wolfe, 2013).”
BackgroundMedically Unexplained Symptoms
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“Heated controversy surrounds this change, with accusations of increased nonspecificity, overinclusiveness, and risk of branding normal behavior as pathological.(17) The history of this evolution of the somatizing conditions of hysteria and hypochondriasis is reflected in the changes in sequential editions of DSM, as s…”
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“This is of particular concern in mental health, as mental health diagnostics and treatment are historically fraught with questions about power, normativity, and inequity (Bergin, Wells, & Owen, 2008; Frances, 2013).”
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“The SSD criteria have been criticized for being very heterogeneous and overinclusive to raise the risk of mislabeling and stigma [20,21].”
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“An appropriate example might concern a seriously medically ill person (e.g., a terminal cancer patient) who justifiably worries greatly yet receives an inappropriate psychiatric pathologizing diagnosis of SSD. Frances (2013a) indicated that SSD could be used to mislabel “a sizeable proportion of the population as ment…”
BackgroundInfluentialAssociation Between Somatization and Nonmotor Symptoms Severity in People With Parkinson Disease
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“Current definition of somatic symptom disorder (SSD) by the DSM-5 is characterized by somatic symptoms that are either very distressing or result in significant disruption of functioning as well as excessive and disproportionate thoughts, feelings, and behaviors regarding those symptoms.(19) Most importantly, the diag…”
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“However, the new SSD category is remarkably non-specific and may lead to many false-positive diagnosis, stigma, and inappropriate treatment [40,41], as some patients with specific physical conditions, e.”
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“Although it is recommended by some authors [6, 7], others warn about the risk of overdiagnosis of a psychiatric pathology, especially when a somatic disease is also present [8, 9].”
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“…somatization disorder, undifferentiated somatoform disorder (SFD), pain disorder, and hypochondriasis (with somatic symptoms) of SFD as defined in DSM-IV, 1 although excessive inclusion of patients is a concern, 3 and can be diagnosed with or without the presence of medical disease (MD).”
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“Instead, pain is posited to result in neurophysiological changes that lead to psychological distress (e.g., excessive worry and behaviors about pain; Frances, 2013).”
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“Of course, one may doubt the validity of the diagnostic labels themselves (e.g. Frances, 2013; Frances & Widiger, 2012), but such a discussion is beyond the scope of our study.”
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“Frauen werden in medizinischen Kontexten häufiger als Männer als unglaubwür-dig eingeschätzt oder ihre realen körperlichen Symptome als psychosomatisch behandelt (vgl. Frances 2013; Foreman 2014).”
Hüsing, P., & Löwe, B. (2025) · Verhaltenstherapie · doi:10.1159/000542766 · Cited by 1 · see citing works
“Die Anwendung iSOMA richtet sich beispielsweise an Er-wachsene mit diversen, belastenden Körperbeschwerden und basiert auf dem bereits erwähnten Manual von Kleinstäuber et al. [2017].”
InfluentialI disturbi di somatizzazione nel DSM-5
Porcelli, P. (2014) · PSICOTERAPIA E SCIENZE UMANE · doi:10.3280/pu2014-003004 · Cited by 1 · see citing works
PTSD und somatoforme Schmerzsymptomatik im Alter
Noll‐Hussong, M. (2014) · Vandenhoeck & Ruprecht eBooks · doi:10.13109/9783666404610.275 · Cited by 1 · see citing works
Orofacial Pain in the Medically Complex Patient
Shephard, M. K., & Heir, G. M. (2019) · Springer eBooks · doi:10.1007/978-3-319-72303-7_38 · Cited by 1 · see citing works
Reading the DSM-5 Through Literature: The Value of Subjective Knowing
Marks, C. (2017) · Palgrave Macmillan UK eBooks · doi:10.1057/978-1-137-51988-7_9 · Cited by 1 · see citing works
Somatic symptom and related disorders
Murray, A., Toussaint, A. C., & Löwe, B. (2017) · doi:10.1093/med/9780198746638.003.0013 · Cited by 1 · see citing works
Medically unexplained symptoms in later life
Hilderink, P. H. (2014) · University of Groningen research database (University of Groningen / Centre for Information Technology) · Cited by 1 · see citing works
Síntomas físicos médicamente no explicados y su clasificación en el DSM-5
López, J. B., García, P. R., & Muñoz, A. M. (2015) · Psiquiatria.com
Ryan, J. (2013) · BMJ · doi:10.1136/bmj.f2235
Die Wege von Kindern und Jugendlichen mit somatoformen Störungen
Kamper, A. (2015) · Pädiatrie & Pädologie · doi:10.1007/s00608-015-0320-1
Leone, F. G. D. (2015) · IPNOSI · doi:10.3280/ipn2015-002001
Lynch, S. (2015) · International Journal of Emergency Mental Health and Human Resilience · doi:10.4172/1522-4821.1000322
“Some criticisms have come from the DSM task force itself, that these concepts may be too broad and inclusive (Frances, 2013), but on other hand may be easier to justify in terms of research evidence and to operationalise.”
BackgroundKlinger, R. (2016) · Springer eBooks · doi:10.1007/978-3-662-50512-0_13
Medically Unexplained Symptoms/Functional Symptoms in Children and Adolescents
McAllister, E., Markham, L., Coughtrey, A. E., & Heyman, I. (2017) · doi:10.1002/9781119170235.ch32
Orofacial Pain in the Medically Complex Patient
Shephard, M. K., & Heir, G. M. (2018) · Springer eBooks · doi:10.1007/978-3-319-28100-1_38-1
Lau, K., Löwe, B., Langs, G., & Voigt, K. (2013) · Psychotherapeut · doi:10.1007/s00278-013-1019-z
- Authors
- Frances, A.
- Corresponding author
- Frances, A.
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2013-03-18
- Volume
- 346
- Issue
- mar18 3
- Pages
- f1580-f1580
- ISSN
- 1756-1833 (ISSN-L)
- OpenAlex
- W2055812845
- Cited by
- 113
- References
- 2
- Citations by year
- 2025: 9 · 2024: 5 · 2023: 7 · 2022: 8 · 2021: 8 · 2020: 9 · 2019: 4 · 2018: 8 · 2017: 8 · 2016: 5 · 2015: 16 · 2014: 9 · 2013: 17
- FWCI
- 11.10
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- BMJ (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Health Sciences › Medicine › Psychiatry and Mental health › Medicine, History, and Philosophy
- Keywords
- somatic symptom disorder, DSM-5, diagnostic criteria, overdiagnosis, diagnostic specificity, psychiatric diagnosis
- MeSH terms
- Mental Disorders, Diagnosis, Differential, Diagnostic Errors, Female, Humans, Male, Somatoform Disorders, Risk Assessment, Diagnostic and Statistical Manual of Mental Disorders
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