BDS, BDDs, BSS, BDD unscrambled

In the context of the drafting of ICD-11 what are Body 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 new 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
18 Self-harm

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 proposed heading for a disorder group, not a proposed disorder category, per se.

For ICD-11 primary care group proposals, it is “Bodily stress syndrome” that has been proposed to replace the ICD-10 primary care diagnosis, F45 Unexplained somatic symptoms [4].

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 (as described in the Lam et al paper) 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 characteristics within its criteria (for which BDS has no requirement) but it also requires multiple symptoms from one or more of four body systems to make the diagnosis.

BSS is conceptualized as a condition related to symptom patterns or clusters of autonomic hyperarousal and the 2012 proposals use the same body systems and symptom lists as Fink et al’s operationalized criteria [5].

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 defining characteristics of Fink et al’s BDS construct but with selected of SSD’s psychobehavioural characteristics tacked on.

What isn’t implicit in the 2012 paper, 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 [5] gives no specific 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-10 entities, for ICD-11. (See slide: Proposed new classification, Fink, Rosendal et al, June 2010)

With Marianne Rosendal on the working group, the PCCG has 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’s 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 [6].

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 concordance with, or partial accommodation of the DSM-5 SSD construct.

Absence of a body of evidence to support the BSS construct’s validity, reliability, safety and clinical utility, and its implications for diagnoses, treatments and management 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 term “Bodily Distress Syndrome” 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 [7].

Currently, in the ICD-11 Beta platform, four discretely coded disorders are listed under:

Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere

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]

Update at January 3, 2014: As the ICD-11 Beta drafting platform stands, at January 3, 2014, the DSM-5 term “(illness anxiety disorder)” has been removed from the “Hypochondriasis (illness anxiety disorder)” disorder name and the term has reverted to “Hypochondriasis.” The term “illness anxiety disorder” is instead listed under “Synonyms” to Hypochondriasis in the ICD-11 Beta Foundation View, and listed under “All Index Terms” in the Morbidity Linearization View.

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.

BDD 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 do not form part of the Fink et al BDS 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.

As described in December 2012, BDD was a fairly close fit for concordance or “harmonization” with the DSM-5 SSD construct [8].

In summary:

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 was anticipated to be undertaken, this year, and 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, last year, to replace F45 Unexplained somatic symptoms and subsume F48.0 Neurasthenia was Bodily stress syndrome.

The discrete category that has been proposed by the S3WG group is Bodily distress disorder.

Last year, BSS (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 had a high degree of correlation with DSM-5’s SSD and poor correlation with Fink et al’s BDS.

For an in depth report on proposals see previous post #265:

Update on ICD-11 Beta drafting: Bodily Distress Disorder: emerging proposals: Part One

Key documents:

1. Fink P, Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res. 2010 May;68(5):415-26.  [Abstract: PMID: 20403500].
2. Slide presentation [PDF format] Somatoform disorders – functional somatic syndromes – Bodily distress syndrome. Need for care and organisation of care in an international perspective – EACLPP Lecture, Prof. Per Fink, MD, Ph.D, Dr.Med.Sc.
3. Part Two of post: ICD-11 Beta draft and Bodily Distress Disorders; Per Fink and Bodily Distress Syndrome:
4. Goldberg DP. Comparison Between ICD and DSM Diagnostic Systems for Mental Disorders. In: Sorel E, (Ed.) 21st Century Global Mental Health. Jones & Bartlett Learning, 2012: 37-53. Free PDF, Sample Chapter Two:
5. Lam TP et al. Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Fam Pract. 2013 Feb;30(1):76-87. [Abstract: PMID:22843638]
6. Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services. Creed, Francis; Henningsen, Peter; Fink, Per, Cambridge University Press, 2011.
7. ICD-11 Beta drafting platform, public version: Bodily distress disorders, and psychological and behavioural factors associated with disorders or diseases classified elsewhere
8. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry 2012;24:556-67. [Abstract: PMID: 23244611]

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