Post #268 Shortlink:
BDS, BDDs, BSS, BDD and ICD-11, unscrambled
There are two WHO convened working groups charged with making recommendations for the revision of ICD-10′s Somatoform Disorders: the Primary Care Consultation Group (known as the PCCG) and the Expert Working Group on Somatic Distress and Dissociative Disorders (known as the S3DWG).
ICD-11 is being promoted as an open and transparent process but to date, neither group has published progress reports for stakeholder consumption and neither group has published its emerging proposals in public access journals.
Content populated in the public version of the ICD-11 Beta drafting platform sheds little light on proposals.
Consequently, there is considerable confusion about what is being recommended by the two groups, whether consensus has been reached, and what proposals will progress to field testing during the coming year.
ICD-11 Revision has been asked to clarify when it intends to define and characterize its current proposals within the Beta drafting platform.
The notes below set out some of what is known about the two groups’ emerging proposals, how they diverge and how they compare with DSM-5′s Somatic Symptom Disorder and with Fink et al’s Bodily Distress Syndrome.
Caveat: the proposals of the two ICD-11 working groups may have undergone revision and refinement since emerging proposals were published, in July and December, last year; the two groups may or may not have reached consensus over how this proposed new construct for ICD-11 should be defined and characterized or its inclusions, exclusions and differential diagnoses, or what name it should be given.
What is Bodily Distress Syndrome (BDS)?
Bodily Distress Syndrome is the name given to a disorder construct developed by Per Fink and colleagues, Aarhus University, that is already in use in Danish research studies and clinical settings .
BDS is described by its authors as “a unifying diagnosis that encompasses a group of closely related conditions such as somatization disorder, fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome.”
Per Fink and colleagues are lobbying for BDS to be integrated into forthcoming classification systems and adopted as a diagnosis by primary care practitioners.
Their proposal is for reclassifying somatoform disorders, pain disorder, neurasthenia and the so-called functional somatic syndromes, including fibromyalgia, irritable bowel syndrome and chronic fatigue syndrome, under a new classification, Bodily Distress Syndrome. They consider these should be treated and managed as subtypes of the same disorder with CBT, GET, “mindfulness therapy” and in some cases, antidepressants.
The PDF format slide presentation in reference  will give an overview of BDS and there is more information and links in an earlier post, in reference .
Is Fink et al’s Bodily Distress Syndrome construct the same as DSM-5′s SSD?
No, Bodily Distress Syndrome is a different construct to DSM-5′s Somatic Symptom Disorder.
Psychological or behavioural characteristics are not part of the BDS criteria.
For BDS, physical symptoms are central to the diagnosis, which is based on identification of symptom patterns (not symptom count) from four body systems: Cardiopulmonary/autonomic arousal; Gastrointestinal arousal; Musculoskeletal tension; General symptoms. There is a “Modest” (single-organ type) and a “Severe” (multi-organ type).
If the symptoms are better explained by another disease, they cannot be labelled BDS.
The graphic below compares mutli-organ Bodily Distress Syndrome with DSM-5′s Somatic Symptom Disorder, as the draft criteria had stood, in May 2012.
Note the defining characteristics of the DSM-5 SSD construct: the SSD criteria call for various psychobehavioural characteristics in response to distressing somatic symptoms and the requirement that the symptoms are “medically unexplained” is not central to the diagnosis.
The diagnosis can be made in the presence of one or more unspecified somatic symptoms associated with general medical conditions and diagnosed disease, like cancer, diabetes or angina, in the so-called “functional somatic syndromes” or in complaints with unclear etiology.
Compare Fink et al’s BDS with DSM-5′s SSD, in the table, below:
Depending on screen size/resolution, graphic may not display in full. Click on the image and the image file will load. Graphic: Suzy Chapman
In the context of the drafting of ICD-11 what are Bodily distress disorders?
The PCCG primary care group that is advising on the revision of the abridged version of ICD-11 was proposing, in 2012, that several, discrete disorders for inclusion in ICD-11-PHC would sit under a disorder group heading, “Body distress disorders” like this:
Body distress disorders:
15 Bodily stress syndrome [Replaces F45 Unexplained somatic symptoms]
16 Acute stress reaction
17 Dissociative disorder
In the context of ICD-11, and in the context of the proposals of the primary care group, at least as they stood last year, the term “Body distress disorders” is a heading for a disorder group, not a disorder category, per se.
For ICD-11 primary care group proposals, it is “Bodily stress syndrome” that is proposed to replace the ICD-10 primary care diagnosis, F45 Unexplained somatic symptoms, and which would incorporate DSM-5′s SSD .
Is the primary care group’s Bodily stress syndrome the same as Fink et al’s Bodily Distress Syndrome?
No, they are not the same construct.
In 2012, the group was still refining its proposed definition and criteria but the characteristics of Bodily stress syndrome might be described as a hybrid of DSM-5′s SSD and Fink et al’s BDS.
It has some SSD-like psychological or behavioural symptoms within its criteria (which BDS has no requirement for) but it also requires multiple symptoms from one or more of four body systems to make the diagnosis.
Like BDS, BSS is conceptualized as a condition related to symptom patterns or clusters of autonomic hyperarousal and the proposals use the same body systems and symptom lists as the Fink et al criteria .
Whilst DSM-5′s SSD makes no assumptions about etiology, BSS is intended to facilitate identification and management of patients with persistent, disabling symptoms not attributable to well-defined medical disease without imposing the additional qualification of being “medically unexplained” – but, “If the symptoms are accounted for by a known physical disease this is not BSS.” In this respect, too, it accords with Fink et al’s BDS.
So the primary care group’s BSS might be considered a mash-up of features very similar to Fink et al’s BDS construct but with selected of SSD’s defining characteristics.
What isn’t clear, is whether the proposals of the primary care group, which are inclusive of the somatoform disorders and what would have been termed “medically unexplained”, under ICD-10, are intended to also capture the specific so-called functional somatic syndromes, CFS, IBS and FM, as the Fink et al construct does.
Paper  gives no exclusions or differential diagnoses for CFS, IBS or FM and is silent on the matter of which of the so-called functional somatic syndromes the definition would extend to, and what the implications would be for the future classification of these three, discretely coded ICD entities, for ICD-11.
With Marianne Rosendal on the working group, the PCCG may have been under pressure to recommend a “pure” Fink et al BDS model, definition and criteria set to replace ICD’s somatoform disorders for ICD-11.
However, we might also anticipate internal WHO pressure for the accommodation of DSM-5′s SSD within any proposals for revision of the ICD’s somatoform disorders, in order to meet the commitment for “harmonization” between DSM-5 and ICD-11 categories and disorder descriptions.
Given that SSD and BDS are acknowledged by Creed, Henningsen and Fink as divergent constructs, this presents the groups advising ICD-11 with a dilemma.
It is unlikely they could call the disorder BDS for the purposes of ICD-11, if their construct did not closely mirror that of Fink et al’s BDS; but they cannot mirror BDS if they also seek to accommodate, or partially accommodate the DSM-5′s SSD construct.
Lack of a body of evidence to support the BSS construct’s validity, reliability and clinical utility and its implications for diagnoses and treatments is beyond the scope of this post.
But proposing a primary care disorder group name of “Body distress disorders” under which it is proposed would sit a “Bodily Stress Syndrome” and three other unrelated disorders, when the terms “Bodily distress disorder” and “Bodily Distress Syndrome” are terms already in use in several countries, and where the latter has a specific definition and criteria set already in use in Denmark, is a curious proposal given the potential for diagnostic and nosological confusion .
In the context of the drafting of ICD-11 what are Bodily distress disorders?
The second ICD-11 working group making recommendations for the revision of the ICD-10 Somatoform Disorders is the WHO Expert Working Group on Somatic Distress and Dissociative Disorders (known as the S3DWG).
Last year, this group’s proposals were for a disorder named Bodily distress disorder .
Currently, in the ICD-11 Beta platform, four discretely coded disorders are listed under:
Bodily distress disorder
Severe bodily distress disorder
Psychological and behavioural factors associated with disorders or diseases classified elsewhere
Hypochondriasis (illness anxiety disorder) [Currently assigned dual parents]
The proposed construct of Bodily distress disorder and its two severity specifiers has remained undefined and uncharacterized for over a year in the public version of the Beta draft.
Is the S3DWG group’s Bodily distress disorder the same as Fink et al’s Bodily Distress Syndrome?
No, they are not congruent.
The Bodily distress disorder framework has a high degree of congruency with DSM-5′s Somatic symptom disorder but may differ from SSD in the characterization of its severities. It also lacks SSD’s Predominately Pain specifer.
The S3DWG group says it prefers the term Bodily distress disorder over DSM-5′s Somatic symptom disorder.
The proposed framework would subsume six ICD-10 categories from F45.0 to F45.9, and F48.0 Neurasthenia under a single new category, called Bodily distress disorder. This corresponds with the SSD construct.
BDD is proposed to be defined as a disorder characterized by high levels of preoccupation related to bodily symptoms and their significance; or persistent fear of having an undiagnosed physical illness; unusually frequent or persistent medical help-seeking or reassurance; avoidance of normal activities for fear of damaging the body, with associated distress and impairment – so it accords, here, with SSD’s requirements for psychobehavioural features in response to distressing somatic symptoms.
By eliminating assumptions about causality, the diagnosis of BDD does not exclude troublesome somatic symptoms in the presence of a co-occurring physical health condition – so again, concords with SSD.
The BDD proposal does not have congruency with the 2012 proposals of the PCCG primary care group since BSS requires symptom clusters from bodily system groups in addition to psychobehavioural features.
BBD does not have congruency with Fink et al’s Bodily Distress Syndrome, since BDS requires symptom clusters from bodily system groups; disproportionate or maladaptive psychological and/or behavioural responses to symptoms do not form part of its criteria.
BDD’s severities appeared to be proposed to be characterized according to assessment of degree of disability and level of distress and impairment, rather than on the basis of psychobehavioural symptom counts, somatic symptom counts, or symptom clusters within specified body systems; or a combination of degree of impairment and number of body system groups affected. But the text lacks sufficient clarity around severity characterization.
At least as described in December, BDD was a fairly close fit for concordance with the DSM-5 SSD construct .
It is not known what definition and characterization ICD-11 will be basing its field testing on for this proposed new disorder, but field testing will be undertaken, this year, and possibly into 2014.
There is still no definition or characterization for BDD in the public version of the ICD-11 Beta drafting platform.
Body distress disorders was the name being proposed, last year, for a primary care disorder group section, containing four discrete and largely unrelated categories, not a discrete disorder, per se.
The discrete category being proposed by the primary care group to replace F45 Unexplained somatic symptoms and subsume F48 Neurasthenia was Bodily stress syndrome.
The discrete category being proposed by the S3WG group is called Bodily distress disorder.
Last year, BSS (PCCG primary care group) was not congruent with DSM-5′s SSD construct but shared some psychobehavioural features with SSD and some disorder model, somatic symptom cluster and body system features with Fink et al’s Bodily distress syndrome.
Last year, BDD (S3DWG) had a high degree of congruency with DSM-5′s SSD.
For an in depth report on proposals see previous post #265: