On 2017 Jul 05, Suzy Chapman commented:

As mentioned in my previous comment, in the literature one observes frequent instances where the term "bodily distress disorder" has been used when what is actually being discussed within the paper or editorial is the Fink et al. (2010) "bodily distress syndrome (BDS)" disorder construct.

For example, "bodily distress disorder" is used interchangeably with "bodily distress syndrome" in the editorial (Creed et al. 2010): Is there a better term than "medically unexplained symptoms"? [1].

In this (Rief and Isaac 2014) editorial: The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? the authors are using the term, "bodily distress disorder" while clearly discussing the Fink et al. (2010) BDS construct [2].

The ICD-11 S3DWG sub working group's proposed term is seen, here, as "Bodily distress disorder (Fink and Schroder 2010)" in Slide #3 of the symposium presentation: An introduction to "medically unexplained" persistent physical symptoms. (Professor Trudie Chalder, Department of Psychological Medicine, King’s Health Partners, 2014) [3].

This paper: Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders (Schumacher et al. 2017) compares prognostic validity of DSM-5 "somatic symptom disorder (SSD)" with "bodily distress disorder (BDD)" and "polysymptomatic distress disorder (PSDD)" and discusses their potential as alternatives to SSD for the replacement of the somatoform disorders for the forthcoming ICD-11 [4].

The authors state, "the current draft of the WHO group is based on the BDD proposal." But the authors have confirmed that for their study, they had operationalized "Bodily distress disorder based on Fink et al. 2007" [5].

In the (Fink et al. 2007) paper: Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients, the authors conclude: "We identified a general, distinct, bodily distress syndrome or disorder that seems to encompass the various functional syndromes advanced by different medical specialties as well as somatization disorder and related diagnoses of the psychiatric classification."

There are other examples in research literature, publications [6] and in the field.

But these examples above suffice to demonstrate that the term, "bodily distress disorder" is already used synonymously with disorder term "bodily distress syndrome (BDS)" and that many researchers and clinicians do not differentiate between the two.

These examples also serve to demonstrate that the "bodily distress disorder" term is already being used outside ICD-11 Beta draft to describe a diagnostic construct that subsumes CFS, ME, IBS and FM under a single, unifying disorder construct - which does not correspond with how ICD Revision has defined "BDD" for the ICD-11 core edition, in which these categories remain discretely classified in chapters outside the Mental, behavioural or neurodevelopmental disorders chapter.

Since researchers/clinicians do not differentiate between "bodily distress syndrome" and "bodily distress disorder" (and in some cases, one also observes the conflations, "bodily distress syndrome or disorder" and "bodily distress syndrome/disorder"), ICD Revision needs to give urgent consideration to the difficulties and implications for maintaining the discrete identity of its proposed disorder, once ICD-11 is released and in the hands of its end users – clinicians, allied health professionals and coders, and to urgently review its current choice of nomenclature.

1 Creed F, Guthrie E, Fink P, Henningsen P, Rief W, Sharpe M, White P. Is there a better term than "medically unexplained symptoms"? J Psychosom Res. 2010 Jan;68(1):5-8. doi:10.1016/j.jpsychores.2009.09.004. [PMID: 20004295]

2 Rief W, Isaac M. The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? Curr Opin Psychiatry September 2014 – Volume 27 – Issue 5 – p315–319. [PMID: 25023885]

3 Chalder, T. An introduction to "medically unexplained" persistent physical symptoms. Presentation, Department of Psychological Medicine, King’s Health Partners, 2014. [Accessed 27 February 2017]

4 Schumacher S, Rief W, Klaus K, Brähler E, Mewes R. Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders. Psychol Med. 2017 Feb 9:1-14. doi: 10.1017/S0033291717000149. [PMID: 28179046]

5 Fink P, Toft T, Hansen MS, Ornbol E, Olesen F. Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients. Psychosom Med. 2007 Jan;69(1):30-9. [PMID: 17244846]

6 Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, Francis Creed, Peter Henningsen, Per Fink (Eds), Cambridge University Press, 2011.

On 2017 Jul 05, Suzy Chapman commented:

In his lecture, Prof Fink discusses DSM-5's "somatic symptom disorder (SSD)" and its alignment with the proposed new diagnostic category, "bodily distress disorder (BDD)", as defined and characterized for the core edition of ICD-11 [1].

Prof Fink notes that SSD is a diagnosis mainly based on psychological and behavioural characteristics, with a very low symptom threshold - only one chronic, disturbing symptom required to meet the criteria, which may or may not be associated with a general medical condition - and suggests this will include most patients seen in both primary and secondary care.

That DSM-5's SSD (and the similarly conceptualized BDD, as defined by ICD-11) risk mislabelling millions of patients with an inappropriate mental disorder diagnosis was identified in 2013 by Frances & Chapman [2] and Frances [3][4].

Prof Fink is rightly concerned that ICD-11's proposed new single category replacement for the ICD-10 somatoform disorders will share the problems inherent in the DSM-5 SSD diagnosis.

However, Prof Fink omits from his lecture a crucial consideration concerning proposed nomenclature.

Since at least 2007, the term "bodily distress disorder" is frequently seen in the literature, at symposia and in presentations being used interchangeably with the term "bodily distress syndrome (BDS)" - the diagnostic construct developed by Prof Fink and his colleagues, which he confirms has been rejected by ICD Revision for inclusion in the ICD-11 core edition.

To the best of my knowledge, no clinician or researcher has published on the potential for confusion and conflation between the two disorder constructs or the implications for maintaining disorder integrity within and beyond ICD-11 - if ICD Revision names its differently conceptualized construct, with its very different criteria set and which potentially captures a different patient population, "bodily distress disorder."

Thus far, ICD Revision has provided no rationale for re-purposing a disorder term that is already closely associated with the Fink et al (2010) disorder construct and criteria set.

There is no justification for introducing a new disorder category into ICD-11 that has greater conceptual alignment with the DSM-5 SSD construct but is proposed to be assigned a disorder name that is closely associated with a divergent (and operationalized) construct/criteria set, that is already in use in research and clinical settings in Denmark and beyond.

This is unsafe and unsound classificatory practice and a very obvious flaw in their recommendations that remains unaddressed.

It is disappointing, then, that whilst having identified problems with clinical utility and given some consideration to the implications for patients for a diagnosis of SSD or its ICD-11 sister diagnosis, the author misses the opportunity to alert his audience to the potential for disorder conflation between ICD-11's proposed "BDD" and his own divergent, "BDS" diagnostic construct.

Comment from the author on this specific issue of nomenclature would be welcomed.

Secondly, there have been two working groups making recommendations to ICD Revision for the revision of the somatoform disorders.

Within his lecture, Prof Fink also refers to the proposals of the ICD-11 Primary Care Consultation Group (PCCG), that is chaired by Prof Sir David Goldberg.

The 28 mental disorders proposed for inclusion in the abridged primary care version (ICD-11 PHC) will require a corresponding category within the core edition. However, the PCCG considers that the "BDD" construct, as defined and characterized for the ICD-11 core edition, lacks utility in primary care settings.

The PCCG's recommendation is for an alternative construct for use in the primary care version which is a modification of the Fink et al (2010) BDS diagnostic construct and criteria set.

Prof Fink states that the PCCG is recommending the name "bodily stress disorder (BSD)" for the new disorder category which it proposes as the replacement for the ICD-10 PHC "F45 Unexplained somatic complaints" category rather than use the name "bodily distress syndrome (BDS)."

But according to Goldberg et al (2017), the PCCG would appear to continue to recommend the term "bodily stress syndrome (BSS)" for their modification - not "bodily stress disorder (BSD)" as Prof Fink has reported [4]. It would be helpful to have this apparent anomaly clarified.

If the PCCG's proposals for the abridged primary care version are approved by WHO/ICD Revision, there will be a lack of correspondence between the ICD-11 core edition replacement for the ICD-10 somatoform disorders and the primary care version.

A lack of consistency between the two editions risks confusion and conflation between the "BSS" BDS modification, the Fink et al (2010) unmodified BDS and the ICD-11 core edition defined BDD, resulting in loss of disorder definition integrity, lack of clarity over which patient populations these constructs are intended to capture, potential misapplication, confusion between different diagnoses across primary care and specialty settings, and will hamper statistical analyses.

Furthermore, and crucially, there appear to be no exclusions or differential diagnoses within the PCCG's proposed "BSS" criteria for CFS, ME, IBS and FM - diagnostic categories that are discretely classified within ICD-11 under chapters outside the mental, behavioural or neurodevelopmental disorders chapter.

This issue is still unaddressed by ICD Revision.

With only a few months left before the Beta draft needs to be finalized, the revision of the somatoform disorders for ICD-11 and ICD-11 PHC remains an indigestible alphabet soup.

1 Gureje O, Reed GM. Bodily distress disorder in ICD-11: problems and prospects. World Psychiatry. 2016 Oct;15(3):291-292. doi: 10.1002/wps.20353. [PMID: 27717252]

2 Allen Frances¹, Suzy Chapman². DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. 1 Department of Psychiatry, Duke University 2 DxRevisionWatch.com Aust N Z J Psychiatry. 2013 May;47(5):483-4.[PMID: 23653063]

3 Frances A. DSM-5 Somatic Symptom Disorder. J Nerv Ment Dis. 2013 Jun;201(6):530-1. doi: 10.1097/NMD.0b013e318294827c [PMID: 23719325]

4 Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013 Mar 18;346:f1580. doi: 10.1136/bmj.f1580. [PMID: 23511949] 5 Primary care physicians' use of the proposed classification of common mental disorders for ICD-11. Goldberg et al. Fam Pract. 2017 May 4. doi: 10.1093/fampra/cmx033. [PMID: 28475675]

On 2017 Jul 05, Suzy Chapman commented:

In his lecture, Prof Fink discusses DSM-5's "somatic symptom disorder (SSD)" and its alignment with the proposed new diagnostic category, "bodily distress disorder (BDD)", as defined and characterized for the core edition of ICD-11 [1].

Prof Fink notes that SSD is a diagnosis mainly based on psychological and behavioural characteristics, with a very low symptom threshold - only one chronic, disturbing symptom required to meet the criteria, which may or may not be associated with a general medical condition - and suggests this will include most patients seen in both primary and secondary care.

That DSM-5's SSD (and the similarly conceptualized BDD, as defined by ICD-11) risk mislabelling millions of patients with an inappropriate mental disorder diagnosis was identified in 2013 by Frances & Chapman [2] and Frances [3][4].

Prof Fink is rightly concerned that ICD-11's proposed new single category replacement for the ICD-10 somatoform disorders will share the problems inherent in the DSM-5 SSD diagnosis.

However, Prof Fink omits from his lecture a crucial consideration concerning proposed nomenclature.

Since at least 2007, the term "bodily distress disorder" is frequently seen in the literature, at symposia and in presentations being used interchangeably with the term "bodily distress syndrome (BDS)" - the diagnostic construct developed by Prof Fink and his colleagues, which he confirms has been rejected by ICD Revision for inclusion in the ICD-11 core edition.

To the best of my knowledge, no clinician or researcher has published on the potential for confusion and conflation between the two disorder constructs or the implications for maintaining disorder integrity within and beyond ICD-11 - if ICD Revision names its differently conceptualized construct, with its very different criteria set and which potentially captures a different patient population, "bodily distress disorder."

Thus far, ICD Revision has provided no rationale for re-purposing a disorder term that is already closely associated with the Fink et al (2010) disorder construct and criteria set.

There is no justification for introducing a new disorder category into ICD-11 that has greater conceptual alignment with the DSM-5 SSD construct but is proposed to be assigned a disorder name that is closely associated with a divergent (and operationalized) construct/criteria set, that is already in use in research and clinical settings in Denmark and beyond.

This is unsafe and unsound classificatory practice and a very obvious flaw in their recommendations that remains unaddressed.

It is disappointing, then, that whilst having identified problems with clinical utility and given some consideration to the implications for patients for a diagnosis of SSD or its ICD-11 sister diagnosis, the author misses the opportunity to alert his audience to the potential for disorder conflation between ICD-11's proposed "BDD" and his own divergent, "BDS" diagnostic construct.

Comment from the author on this specific issue of nomenclature would be welcomed.

Secondly, there have been two working groups making recommendations to ICD Revision for the revision of the somatoform disorders.

Within his lecture, Prof Fink also refers to the proposals of the ICD-11 Primary Care Consultation Group (PCCG), that is chaired by Prof Sir David Goldberg.

The 28 mental disorders proposed for inclusion in the abridged primary care version (ICD-11 PHC) will require a corresponding category within the core edition. However, the PCCG considers that the "BDD" construct, as defined and characterized for the ICD-11 core edition, lacks utility in primary care settings.

The PCCG's recommendation is for an alternative construct for use in the primary care version which is a modification of the Fink et al (2010) BDS diagnostic construct and criteria set.

Prof Fink states that the PCCG is recommending the name "bodily stress disorder (BSD)" for the new disorder category which it proposes as the replacement for the ICD-10 PHC "F45 Unexplained somatic complaints" category rather than use the name "bodily distress syndrome (BDS)."

But according to Goldberg et al (2017), the PCCG would appear to continue to recommend the term "bodily stress syndrome (BSS)" for their modification - not "bodily stress disorder (BSD)" as Prof Fink has reported [4]. It would be helpful to have this apparent anomaly clarified.

If the PCCG's proposals for the abridged primary care version are approved by WHO/ICD Revision, there will be a lack of correspondence between the ICD-11 core edition replacement for the ICD-10 somatoform disorders and the primary care version.

A lack of consistency between the two editions risks confusion and conflation between the "BSS" BDS modification, the Fink et al (2010) unmodified BDS and the ICD-11 core edition defined BDD, resulting in loss of disorder definition integrity, lack of clarity over which patient populations these constructs are intended to capture, potential misapplication, confusion between different diagnoses across primary care and specialty settings, and will hamper statistical analyses.

Furthermore, and crucially, there appear to be no exclusions or differential diagnoses within the PCCG's proposed "BSS" criteria for CFS, ME, IBS and FM - diagnostic categories that are discretely classified within ICD-11 under chapters outside the mental, behavioural or neurodevelopmental disorders chapter.

This issue is still unaddressed by ICD Revision.

With only a few months left before the Beta draft needs to be finalized, the revision of the somatoform disorders for ICD-11 and ICD-11 PHC remains an indigestible alphabet soup.

1 Gureje O, Reed GM. Bodily distress disorder in ICD-11: problems and prospects. World Psychiatry. 2016 Oct;15(3):291-292. doi: 10.1002/wps.20353. [PMID: 27717252]

2 Allen Frances¹, Suzy Chapman². DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. 1 Department of Psychiatry, Duke University 2 DxRevisionWatch.com Aust N Z J Psychiatry. 2013 May;47(5):483-4.[PMID: 23653063]

3 Frances A. DSM-5 Somatic Symptom Disorder. J Nerv Ment Dis. 2013 Jun;201(6):530-1. doi: 10.1097/NMD.0b013e318294827c [PMID: 23719325]

4 Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013 Mar 18;346:f1580. doi: 10.1136/bmj.f1580. [PMID: 23511949] 5 Primary care physicians' use of the proposed classification of common mental disorders for ICD-11. Goldberg et al. Fam Pract. 2017 May 4. doi: 10.1093/fampra/cmx033. [PMID: 28475675]

On 2017 Jul 05, Suzy Chapman commented:

As mentioned in my previous comment, in the literature one observes frequent instances where the term "bodily distress disorder" has been used when what is actually being discussed within the paper or editorial is the Fink et al. (2010) "bodily distress syndrome (BDS)" disorder construct.

For example, "bodily distress disorder" is used interchangeably with "bodily distress syndrome" in the editorial (Creed et al. 2010): Is there a better term than "medically unexplained symptoms"? [1].

In this (Rief and Isaac 2014) editorial: The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? the authors are using the term, "bodily distress disorder" while clearly discussing the Fink et al. (2010) BDS construct [2].

The ICD-11 S3DWG sub working group's proposed term is seen, here, as "Bodily distress disorder (Fink and Schroder 2010)" in Slide #3 of the symposium presentation: An introduction to "medically unexplained" persistent physical symptoms. (Professor Trudie Chalder, Department of Psychological Medicine, King’s Health Partners, 2014) [3].

This paper: Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders (Schumacher et al. 2017) compares prognostic validity of DSM-5 "somatic symptom disorder (SSD)" with "bodily distress disorder (BDD)" and "polysymptomatic distress disorder (PSDD)" and discusses their potential as alternatives to SSD for the replacement of the somatoform disorders for the forthcoming ICD-11 [4].

The authors state, "the current draft of the WHO group is based on the BDD proposal." But the authors have confirmed that for their study, they had operationalized "Bodily distress disorder based on Fink et al. 2007" [5].

In the (Fink et al. 2007) paper: Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients, the authors conclude: "We identified a general, distinct, bodily distress syndrome or disorder that seems to encompass the various functional syndromes advanced by different medical specialties as well as somatization disorder and related diagnoses of the psychiatric classification."

There are other examples in research literature, publications [6] and in the field.

But these examples above suffice to demonstrate that the term, "bodily distress disorder" is already used synonymously with disorder term "bodily distress syndrome (BDS)" and that many researchers and clinicians do not differentiate between the two.

These examples also serve to demonstrate that the "bodily distress disorder" term is already being used outside ICD-11 Beta draft to describe a diagnostic construct that subsumes CFS, ME, IBS and FM under a single, unifying disorder construct - which does not correspond with how ICD Revision has defined "BDD" for the ICD-11 core edition, in which these categories remain discretely classified in chapters outside the Mental, behavioural or neurodevelopmental disorders chapter.

Since researchers/clinicians do not differentiate between "bodily distress syndrome" and "bodily distress disorder" (and in some cases, one also observes the conflations, "bodily distress syndrome or disorder" and "bodily distress syndrome/disorder"), ICD Revision needs to give urgent consideration to the difficulties and implications for maintaining the discrete identity of its proposed disorder, once ICD-11 is released and in the hands of its end users – clinicians, allied health professionals and coders, and to urgently review its current choice of nomenclature.

1 Creed F, Guthrie E, Fink P, Henningsen P, Rief W, Sharpe M, White P. Is there a better term than "medically unexplained symptoms"? J Psychosom Res. 2010 Jan;68(1):5-8. doi:10.1016/j.jpsychores.2009.09.004. [PMID: 20004295]

2 Rief W, Isaac M. The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? Curr Opin Psychiatry September 2014 – Volume 27 – Issue 5 – p315–319. [PMID: 25023885]

3 Chalder, T. An introduction to "medically unexplained" persistent physical symptoms. Presentation, Department of Psychological Medicine, King’s Health Partners, 2014. [Accessed 27 February 2017]

4 Schumacher S, Rief W, Klaus K, Brähler E, Mewes R. Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders. Psychol Med. 2017 Feb 9:1-14. doi: 10.1017/S0033291717000149. [PMID: 28179046]

5 Fink P, Toft T, Hansen MS, Ornbol E, Olesen F. Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients. Psychosom Med. 2007 Jan;69(1):30-9. [PMID: 17244846]

6 Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, Francis Creed, Peter Henningsen, Per Fink (Eds), Cambridge University Press, 2011.