Nosology

Attempts to identify the mechanisms involved in the pathogenesis of unexplained physical symptoms extend as far back as ancient Egyptian times, when the prevailing view attributed their origin to a "hysterical" process involving abnormal movements of the uterus within the sufferer's body (the ancient Greek hyster-o«="uterus"). Although the so-called "wandering womb'' hypothesis lost favor almost 2000 years ago, the term hysteria continued to be used as a generic label for the occurrence of medically unexplained symptoms until 1980, when the terms hysteria and hysterical were eliminated from the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and two new superordinate categories, subsequently refined in DSM-IV, were created to capture the basic elements of the hysteria concept (Table I). The somatoform disorders category encompasses a range of complaints characterized by the symptoms of somatic illness (e.g., pain, fatigue, and nausea) in the absence of underlying physical pathology. Broadly speaking, DSM-IV categorizes somatoform complaints according to the nature, number, and duration of the unexplained symptoms in question. The soma-tization disorder category corresponds to the traditional conception of hysteria as a syndrome characterized by large numbers of unexplained symptoms across multiple bodily systems (also known as Briquet's syndrome). A DSM-IV diagnosis of somatization disorder (onset before the age of 30) requires a history of unexplained pain in at least four different bodily sites, at least two unexplained gastrointestinal symptoms, at least one unexplained sexual or reproductive symptom, and at least one unexplained neurological symptom. The undifferentiated somato-form disorder category includes less severe cases, in which unexplained symptoms have persisted for at least 6 months but are fewer in number and may be less disabling. Similar unexplained symptoms of a shorter duration are categorized as instances of somatoform disorder not otherwise specified. Each of the latter categories encompasses all possible physical symptoms, with the exception of unexplained neurological phenomena, which are categorized separately as

Table I

Classification of Somatoform and Dissociative Disorders in DSM-IV

Table I

Classification of Somatoform and Dissociative Disorders in DSM-IV

Somatoform disorders

Dissociative disorders

Somatization disorder

Dissociative amnesia

Undifferentiated somatoform

Dissociative fugue

disorder

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