Is it used correctly? Does it improve the clinical outcome? So far, it has not been described to what extent BDS is would be used in everyday general practice. This is partly because BDS is a new diagnostic category which has not yet been incorporated in the current diagnostic classification systems, and partly because the construct of BDS has not been investigated in implementation studies. In most countries, the health-care system does not offer sufficient if any treatment programmes for patients with functional disorders. This would affect the diagnostic utility of any diagnosis.
If no treatment options are available, or a diagnostic category has direct negative consequences for the patient, the GP will obviously be reluctant to use such a diagnosis. The lacking treatment options may also lead to low acceptance of BDS and, ultimately, increased risk of stigmatisation. The user acceptability of BDS has been explored in focus group interviews about general views on the diagnosis among GPs; these interviews were completed in seven countries in connection with the upcoming primary health-care version of the ICD on mental health. There was general agreement that this disorder does exist, but no clear consensus was reached on the proposed diagnostic criteria [ 84 ].
Further rating of user acceptability and translation of BDS into clinical practice is currently being conducted in field trials worldwide under the auspices of the World Health Organisation [ 84 ]. Whether BDS is easy to use in general practice remains to be examined. However, the fact that BDS has a clear classification algorithm, and that a diagnostic aid, the BDS checklist, has been developed, is in favour of the feasibility [ 43 ].
Also the improved conceptualisation provided through theoretically based hypotheses on aetiology may form the basis for a set of explanatory models which could serve as satisfactory candidates for both physicians and patients [ 84 , 95 , 96 ]. Furthermore, whether BDS is used correctly or, most importantly, whether BDS may lead to an improvement of the clinical outcome for patients with functional disorders remains to be investigated.
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Data collected for clinical assessment of patients with multi-organ BDS show a high degree of patient acceptability [ 97 ], and multi-organ BDS has been used as an inclusion criterion in several clinical trials with low drop-out rates [ 45 , 46 ]. It is unknown whether the reported acceptability is generalisable to other patient groups. It is often discussed whether psycho-behavioural characteristics should form part of the diagnostic criteria for functional disorders [ 47 ].
BDS has been shown to include most patients with somatoform disorders, even when psycho-behavioural characteristics are not included in the diagnostic criteria [ 40 ]. This may indicate that although behavioural and cognitive factors are associated with pathogenesis of functional disorders [ 60 ], they may not be prerequisite as diagnostic criteria. A useful diagnostic category may improve the clinical communication.
In this regard, terminology is closely linked to classification as names convey information and meaning by their etymology, associations and connotations [ 95 ].
Medically Unexplained Symptoms, Somatisation and Bodily Distress : Francis Creed :
An international group of experts has recommended using a non-stigmatising term, which should be neutral in terms of aetiology and pathology, for this diagnosis; bodily distress syndrome has been considered an option [ 5 ]. In some languages, e. The terminology discussion seems to continue, even after the proposition of BDS, which is probably because the meaning of the term may vary depending on language and cultural context.
Some authors seem to regard BDS as a diagnosis which does not enhance a non-dualistic clinical approach because other relevant differential diagnoses must first be ruled out in order to diagnose a patient with BDS [ 47 ]. Two issues will be addressed regarding this viewpoint. For a BDS diagnosis, the symptoms and the pattern they form must be considered in combination. The physician must, therefore, inquire about symptoms of BDS to identify a characteristic illness picture in the same way as for the diagnostic work-up of any medical or psychiatric condition.
It appears less futile to assess whether the expression of the condition as a whole most likely is caused by a well-defined medical condition because a symptom pattern is more specific than single symptoms; symptoms that in the case of functional disorders are often vague and very common. Second, every time a clinician reaches any diagnosis for a patient several differential diagnoses must first be taken into consideration and a disease hypothesis must be tested.
In this sense, BDS is not any different. BDS is a diagnostic category that fulfils several important validators for clinical syndromes. However, the current knowledge on the utility of the diagnosis is sparse, and BDS has, so far, been implemented only in specialised health-care settings.
Future intervention studies should investigate the translation of BDS into clinical practice and should direct a special focus on the acceptability of the BDS construct among GPs and patients; whether it is used and, most importantly, whether it seems to guide treatment and improve the clinical outcome for the affected patients. However, in order to evaluate the performance and the required adaptation of the BDS construct, training of the health-care professionals is essential, as it is when any new concept is introduced in clinical practice.
A major advantage of the BDS diagnosis is that it has been explored in empirical studies, including primary-care populations. On the other hand, BDS does not embrace all patients with impairing symptoms; a small group of patients with either rare functional symptom patterns or only very few disabling symptoms or just one disabling symptom are not included in the category. In addition, all studies on BDS have been conducted in countries of the Western world. The lacking knowledge of the validity of BDS in the developing countries is a drawback.
However, field trials studies are being performed worldwide including primary care populations from Brazil, Mexico, Spain, Pakistan and Hong Kong under the auspices of World Health Organization. Finally, the term itself may be a challenge as it translates poorly into some languages and may contribute to dualism, e.
Reactions to diagnoses of functional disorders vary broadly and there is a need to find common ground and concept. The BDS concept may offer an evidence-based path for uniformly categorising patients with functional disorders and may help relieve some of the classification confusion caused by the existing numerous overlapping labels. Furthermore, BDS may provide the GP with a diagnosis which is more suitable for the clinical picture seen in general practice and opens up for tangible explanatory models. In combination, this may entail more consistent patient management and may also form the basis for more homogeneous research in prevention and improved treatment strategies; hence BDS holds the potential for better patient outcomes.
Competing interests. All authors contributed to the idea of this paper. MV and PF contributed to the background and discussion. All authors provided critical revision of the manuscript and have approved the final version of this article. Per Fink, Email: kd. Mogens Vestergaard, Email: kd. Marianne Rosendal, Email: kd. National Center for Biotechnology Information , U. BMC Fam Pract. Published online Dec Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Received Jun 8; Accepted Dec 3.
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This article has been cited by other articles in PMC. Abstract Background Conceptualisation and classification of functional disorders appear highly inconsistent in the health-care system, particularly in primary care. Discussion A growing body of evidence suggests that the numerous diagnoses for functional disorders listed in the current classifications belong to one family of closely related disorders.
Summary Bodily distress syndrome is a diagnostic category with notable validity according to empirical studies. Keywords: Bodily distress syndrome, Functional disorders, General practice, Diagnosis, Diagnostic utility, Diagnostic validity, Medically unexplained symptoms.
Background Many primary-care patients complain of symptoms which cannot be attributed to any conventionally defined medical disease or mental disorder [ 1 — 3 ]. Discussion and conclusions The nature of bodily distress A growing body of evidence suggests that the many different functional somatic syndromes and somatoform disorders listed in the current classifications belong to a family of closely related disorders, or that they are expressions of the same underlying illness phenomenon with various subtypes [ 2 , 8 , 40 , 43 , 48 — 50 ].
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Open in a separate window. The diagnostic category of BDS The diagnostic category of BDS is based on the symptom groups pertaining to bodily distress and introduces symptom pattern recognition as a core element of the diagnostic criteria. Table 1 Diagnostic criteria for BDS. How does BDS fulfil the principles of diagnostic validity and clinical utility? Table 2 Validators and utility of clinical syndromes, as well as established evidence regarding BDS.
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No studies found Is it acceptable to users? Lam et al. No studies found Is it used correctly? No studies found Does it improve clinical outcome? No studies found Does it enhance communication? The diagnostic validity and BDS In favour of the validity of BDS is the fact that the clinical description of the BDS symptom profiles originates from principal component analyses analysis based on data from a large study of patients from internal medical and neurological departments and from primary care. The additional validity criteria and BDS The population used for developing the BDS diagnosis is partly representative of primary care as the BDS criteria were based on empirical data from both primary- and secondary-care populations.
Patient acceptability Data collected for clinical assessment of patients with multi-organ BDS show a high degree of patient acceptability [ 97 ], and multi-organ BDS has been used as an inclusion criterion in several clinical trials with low drop-out rates [ 45 , 46 ].
Are psycho-behavioural characteristics a prerequisite for the diagnostic criteria? Terminology A useful diagnostic category may improve the clinical communication. Does BDS enhance a non-dualistic approach to functional disorders? Summary BDS is a diagnostic category that fulfils several important validators for clinical syndromes.
Footnotes Competing interests M. References 1. Classification of somatization and functional somatic symptoms in primary care. Aust N Z J Psychiatry. Symptoms and syndromes of bodily distress: an exploratory study of internal medical, neurological, and primary care patients. Psychosom Med. Fink P, Rosendal M. Recent developments in the understanding and management of functional somatic symptoms in primary care. Curr Opin Psychiatry. Medically unexplained symptoms in family medicine: defining a research agenda. Fam Pract. J Psychosom Res. American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders.