There are two articles on this page:

1. On the Misdiagnosis of Somatization Disorder in Gulf War Veterans and the Relevance of Related Terms - A MUST read!!

2. Somatization Disorder, Organophosphate Poisoning or Overlapping Syndromes of Chronic Fatigue, Fibromyalgia and Multiple Chemical Sensitivity?

14 February 1996, updated 13 June 1997 for presentation to the VA Persian Gulf Expert Scientific Committee

by Albert Donnay, MHS, Executive Director, MCS Referral & Resources, 508 Westgate Rd, Baltimore MD 21229, 410-362-6400, fax 362-6401

Many Gulf War veterans with otherwise "unexplained" illness are being given the psychiatric diagnosis of SOMATIZATION disorder by physicians at the Departments of Defense (DoD) and Veterans' Affairs (VA). According to Stedman's Medical Dictionary, this means the "the conversion of anxiety into physical symptoms." In practice, the diagnosis is commonly given to patients who report a variety of subjective symptoms for which no physical signs or other evidence can be found.

The VA and DoD physicians who are diagnosing SOMATIZATION disorder in so many previously SOMATOTONIC Gulf War veterans ("a personality type characterized by vigorous activity and assertiveness") clearly don't know much about SOMATOPSYCHIC MEDICINE (defined as "the study of the effects of the body upon the mind"). If they did, they'd be less hostile to the views of SOMATISTS ("one who believes that neuroses and psychoses are manifestations of organic disease") and better able to distinguish the psychiatric diagnosis of SOMATOPHRENIA ("a tendency to imagine or exaggerate body ills") from everyday SOMATHESIA ("bodily sensation, the consciousness of the body") and true SOMATOGENIC DISORDERS ("originating in the soma or body under the influence of external forces").

These disorders range from the rare and perplexing SOMATAGNOSIA, defined as "the inability of the patient to identify parts of his own body and parts of the observer's body," to the relatively common SOMASTHENIA, also called SOMATASTHENIA, "a condition of chronic physical weakness and fatigability" (very much like Chronic Fatigue Syndrome).

Ironically, the entry immediately preceding SOMASTHENIA in Stedman's Medical Dictionary is for the nerve gas SOMAN, "an extremely potent cholinesterase inhibitor," to which thousands of Gulf War veterans may have been exposed at Kamisiyah and elsewhere. Even more US troops were exposed to pyridostigmine bromide, a supposedly reversible "cholinesterase inhibitor" that also could have contributed to the veterans' SOMASTHENIA and other SOMATOGENIC disorders.

Despite the obvious physical suffering of Gulf War veterans, DoD and VA physicians are reluctant to treat their "ill-defined complaints" as SOMATALGIA ("pain due to organic causes, as opposed to psychalagia or psychogenic pain"). They clearly prefer psychiatric diagnoses, psychiatric medications, and psychiatric treatments--even though none have been shown to improve the health of veterans with Gulf War Syndrome. That DoD and VA doctors so often fail to consider physical symptoms and external factors in their differential diagnoses suggests a new condition that perhaps should be called DIAGNOSTOPHRENIA: "the tendency of physicians obsessed with psychiatric labels to overlook the signs and symptoms of organic illness."

26 February 1996, update 13 June 1997 for presentation to the VA Persian Gulf Expert Scientific Committee

by Albert Donnay, MHS, Executive Director, MCS Referral & Resources, 508 Westgate Rd, Baltimore MD 21229, 410-362-6400, fax 362-6401

According to the somatization section of the standard Diagnostic Interview Survey (DIS-III-R) and the ICD-9CM Diagnostic Coding Manual, the formal diagnosis of somatization disorder is supposed to be given only to patients who report at least 13 of the 35 specific subjective symptoms (31 for men) for which no physical evidence or medical explanation can be found.

These symptoms are presented in the table below. The 4 at the end apply to women only. The 7 symptoms in bold (+) are the most common and recommended for initial screening. If the patient's medical records offer an explanation for a symptom, it should not be counted. Note, for example, that the 13 symptoms marked with an asterisk (*) are also symptoms of organophosphate poisoning.

Symptoms of Somatization (minimum 13)

+ * Vomiting (other than pregnancy)

+ * Pain in extremities

+ * Shortness of Breath

+ Difficulty Swallowing

+ Burning sensation in sexual organs or rectum other than during sex

* Nausea

* Abdominal pain

+ Amnesia

Double vision

Difficulty urinating

Bloating

Back pain

* Palpitations

* Blurred vision

Impotence

* Diarrhea

* Joint pain

Dizziness

Blindness

Intolerance of different foods

* Chest pain

Deafness

Fainting / loss of consciousness

* Muscle weakness

Pain during urination

* Trouble walking

Pain during sex

* Seizure or convulsion

Other pain, excl. headaches

Loss of voice

Sexual indifference

Vomiting throughout pregnancy

Excessive menstrual bleeding

+ Painful menstruation

Irregular periods

Of the Top 10 symptoms reported by Gulf War veterans (in the DoD's CCEP), only 3 are listed among these 35: joint paint, other (muscle) pain, and diarrhea. The other 7 in the are chronic fatigue, headache, memory loss, sleep disturbances, skin rashes, difficulty concentrating, and depression.

While clearly not characteristic of somatization, all of the Top 10 are characteristic of Chronic Fatigue Syndrome, Fibromyalgia Syndrome, and Multiple Chemical Sensitivity.

Given this overlap, it is not surprising that these disorders also do not fit the definition of somatization. In a "Controlled Comparison of Multiple Chemical Sensitivities and Chronic Fatigue Syndrome" (Psychosomatic Medicine, 1996, 58:38-49) Fiedler et al found that the majority of both MCS (n=22) and CFS (n=17) patients reported less than the 13 required symptoms. The means were 8.4 for MCS of acute onset, 6.5 for MCS of non-acute onset, and 10.8 for CFS, despite the structural bias of the review process that the authors admit favored the designation of somatization criteria. Only 18% of acute-onset MCS, 10% of non-acute-onset MCS, and 12% of CFS met the somatization criteria, and these rates were not even statistically significant compared to the normal controls.

An earlier study by Ahels et al on the "Psychiatric status of patients with primary fibromyalgia, patients with rheumatoid arthritis, and subjects without pain: a blind comparison of DSM-III diagnoses" (Am. J. Psychiatry, 1991, 148(12):1721-6) found fibromyalgia patients without a psychiatric history were no more likely to endorse somatic symptoms than were arthritis patients or subjects without pain.