356 CHAPTER 8
Criticism of the DSM-IV-TR Criteria
The DSM-IV-TR criteria for SD have been criticized on several grounds. First, the
diagnosis is based on a simple counting of symptoms, so that each symptom is treated
as equally important, regardless of how long it has persisted or how severe it is (Crite-
rion B). However, some symptoms are more disabling than others, and chronic symp-
toms are likely to be more disabling than transient ones. Moreover, the minimum
number of each type of symptom needed for the diagnosis was not based on research,
but rather was set arbitrarily by the DSM-IV committee. That said, there is a simple
defense of the method of counting symptoms used in DSM-IV-TR: studies fi nd that
the greater the number of medical symptoms an individual has, the more impaired he
or she is likely to be (Barsky, Orav, & Bates, 2005; Jackson et al., 2006).
Second, the criteria do not address patients’ behaviors nor their beliefs or attri-
butions about their bodily symptoms (Holder-Perkins & Wise, 2001). Such factors
are incorporated into the diagnostic criteria for panic disorder (see Chapter 7), and
in some ways, SD is similar to panic disorder: Both involve a preoccupation withPeople with SD may avoid certain activities that they believe are associated with
their bodily symptoms, such as any type of exercise. In so doing, patients attempt to
minimize the physical sensations associated with the disorder. Unfortunately, they
then become so out of shape that even normal daily activities, such as walking to the
store from the parking lot, may lead them to experience bodily symptoms, creating a
vicious cycle of avoidance and increased bodily symptoms. For people with SD, these
symptoms impair daily life, which is what happened to Edward in Case 8.5.In an effort to minimize their bodily symptoms,
people with somatization disorder may restrict
their activities. However, inactivity can create ad-
ditional symptoms (such as back pain) or make
existing symptoms worse (such as increased
heart rate or diffi culty breathing). theboone/iStockphoto.com
CASE 8.5 • FROM THE OUTSIDE: Somatization Disorder
As an infant, Edward had scarlet fever and a mild form of epilepsy, from which he recovered.
By school age, he was complaining of stomachaches and joint pain and often missed school.
There were many doctors, but no dire diagnosis: Edward was healthy, but many commented, a
somewhat lonely and serious little boy.
Through high school and college Edward capitalized on those traits, achieving high
grades and going into the insurance business. At forty-five, he is plagued by mysteri-
ous symptoms—heart palpitations, dizziness, indigestion, pain in his shoulders, back,
and neck, and fatigue—and lives with his parents. His physical disabilities have made it
impossible for Edward to hold a job, and his engagement was broken off. He remains on
disability and spends much of his time in and out of hospitals undergoing various tests
and procedures.
(Cantor, 1996, p. 54)