Fibromyalgia syndrome—a bodily distress disorder/somatic symptom disorder? 2025 Häuser et al

Introduction:
The debate addressing the classification of chronic widespread pain as a physical disorder (fibromyalgia syndrome) [FMS] or a somatoform disorder according to psychiatric classification systems has continued for decades.

Objectives:
The review aims to line out the new perspectives introduced by the 11th version of the International Classification of Diseases (ICD 11) of the World Health Organization (WHO).

Methods:
Critical review of the classification criteria of fibromyalgia syndrome and bodily distress disorder in ICD 11.

Results:
Fibromyalgia syndrome has been eliminated from the chapter of diseases of the musculoskeletal system and is now included in a chapter “Symptoms, signs, clinical forms, and abnormal clinical and laboratory findings, not elsewhere classified“. Previously, the ICD-10 diagnosis of somatoform disorder was often used by mental health care disciplines instead of the label FMS. Somatoform disorders category has been eliminated as a diagnostic category in the ICD-11 and the 5th version Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (APA) and has been replaced with the new categories of bodily distress disorder (BDD) and somatic symptom disorder (SSD) respectively. For diagnosis, these latter mental disorders require at least one distressing somatic symptom (e.g. pain) plus positive psychobehavioral criteria, namely „excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns“, without the condition that distressing somatic symptoms have to be medically unexplained.

Conclusion:
We argue that the psychobehavioral criteria of BDD/SSD are imprecisely defined and can be misinterpreted as for „Excessive health concerns“ which may occur due to the many uncertainties surrounding FMS or „Excessive time devoted to the symptoms“ which may be related to patient self-management strategies.

Open access

 

What’s with the psych field’s obsession with «excessive» behaviour? How would you even define the threshold for excessive - do you have to define it for every illness?

The more I learn about psych, the worse it gets.

 

Simple. If you’re in widespread pain of unknown source and you think about it, have feelings about it or it affects your behaviours, it’s excessive. If you just keep quiet and don’t seek treatment, assistance, research etc it’s not excessive. If you bother a medic, it’s excessive.

 

We refuse to believe we have limited knowledge and might not be able to help you. So if it’s pain we cannot find the cause ergo treat, your pain is excessive, and instead we will refer you to treatment for your “delusions”.

 

I’m glad someone in on the case with spotting this development and its dangers for fibromyalgia too

I think that change to SSD not needing to exclude there being a physical cause is such a dangerous step backwards and seems very invalid (you in effect have one ‘syndrome’ or set of symptoms, one of which is validated and physical and the other is based only on insisting on rewording those symptoms as ‘behaviours’ by calling pain as pain relief seeking or pain-reacting behaviours and claiming an invalidated ‘cause’ that must surely be implicitly based on the assumption there is ‘no cause’) and logically inconsistent - I almost don’t know how it stands given the ambitions of it being used to expand its usage to categories which it doesn’t/shouldn’t apply seems so clear?

it feels like territory-grabbing based on reversing the laws of logic to capture patients , as if the implications for said patients don’t matter and it’s a game ‘fir numbers’

 

It reminds me of the doctors under the Maoist rule. They couldn’t diagnose depression in their patient as that was a dissident political act, to be in any way discontent with the magnificent regime, and the patient would be arrested. We all just need to pretend not to be ill.

 

6C20 Bodily distress disorder

Bodily distress disorder is characterised by the presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms, which may be manifest by repeated contact with health care providers. If another health condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression.
(…)

Exclusion:
(…)
Postviral fatigue syndrome(8E49)
Chronic fatigue syndrome(8E49)
Myalgic encephalomyelitis(8E49)

Explained by the people involved:
Oye Gureje1, Geoffrey M. Reed2, 2016

Bodily distress disorder in ICD‐11: problems and prospects

Dropping the criterion of “medically unexplained” is not without its consequences and has been criticized in somatic symptom disorder. It has been argued that patients with medical conditions and with a justifiable reason for somatic complaints may receive an inappropriate psychiatric diagnosis, with the possibility of associated stigma8. The specification in bodily distress disorder that “if a medical condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression” is meant to address this concern.

Innovations and changes in the ICD‐11 classification of mental, behavioural and neurodevelopmental disorders

Importantly, bodily distress disorder is defined according to the presence of essential features, such as distress and excessive thoughts and behaviours, rather than on the basis of absent medical explanations for bothersome symptoms, as in ICD‐10 somatoform disorders.

Why not use both?!

They also fail to mention that the critics pointed out that the old definitions were too wide, and would capture 15 % of cancer and heart patients, and 25 % of IBS patients:

https://journals.lww.com/jonmd/fulltext/2013/06000/dsm_5_somatic_symptom_disorder.13.aspx

 

I honestly don’t get it. Doctors aren’t omniscient, so you have no damn clue if someone’s distress is excessive.

And in any case, telling someone with distress that their distress is excessive or their symptoms aren’t real, is just going to cause more distress.

 

They don’t use both because the whole aim of the change is to justify removing having to exclude these behaviours ‘being explained by a medical condition’ ie normal by claiming ‘of course it will only be if it is excessive’

except look at anxiety as a definition - that isn’t calibrated to the situation someone is in - so it feels one of those false promises

particularly as the symptoms (which they call behaviours) chosen in the propaganda/papers for it tend to be those of MUS/FND/Fibro/CFS and they also tend to put in buzz words/dog whistles like ‘medically unexplained’ along with a description of ‘whose face fits’ demographic wise and a flase narrative story (childhood trauma) as a cover all to assume.

Importantly I imagine things like the FND papers which then start to suggest ‘one in ten’ will have this tgat someone will see. and know that will act like a target - because they deliberately write it to infer those who aren’t finding that many ‘must be failing at their spot the difference puzzles’

And of course that correlates magically to the % of eg female patients of x age that will be at their door.

hey presto instead of diagnose by medical information they then manage to get something quite different occurring. Everyone must ‘keep up their targets’ of what is actually shipping off that demographic to a diagnosis that has rated their symptoms on ‘the scale of imagination’ instead of ‘the scale of symptoms’ and instead of being based on work up and history based on looking for any symptoms being ‘behaviours’ and scrabbling to find things to back up a narrative to explain it.

I think the impact of just these two definitions being allowed is huge, but the wider implications of them being allowed to stand and influence the way doctors approach diagnoses in general could be even more huge.

 

Yes. But only because they have a “distressed personality” and everything causes them excessive distress.

 

This is always a thing. Who's to say whether distress is "excessive"? Seems very grandiose.

 

Which is QED. Evidence in itself. Because the distress is interpreted as its own cause. They built a system in which heads they are right, tails they are right, don't throw the coin they are right, lands sideways they are also right. They are literally always right no matter what. Hence zero learning in decades of miserable failure, which they genuinely interpret as success.

Honestly this is a higher level of insanity. It merits its own category. It's delusion of grandeur massively amplified in an echo feedback loop of failure, where the more they fail, the more they are convinced of succeeding, which makes them fail even worse.

They basically built the perfect system of failure. Like one of those Chinese finger traps, where the more you struggle the tighter it gets. Except it's failure and millions of human lives instead of a finger but they are in such a state of failure that they literally can't tell the difference between good and bad outcomes. Because they can't look, and don't ever bother looking.

 

And even when they play sophist when someone flags eg the issue with anxiety diagnosis not looking at situation-first they try and change the frame to suggest ‘but don’t those going through hard times need help for that distress’

except they don’t say that their ‘help’ if they aren’t doing it this way involves an attitude of not tackling and making unacceptable putting people long term into those situations. And not tackling that it shouldn’t indeed even with ‘tools and support’ be left that way for long term

but that’s the bps attitude for you - human being should have no limits, as long as it isn’t them (the same people who do this tend to be both over sensitive and don’t put up with a fraction of any of the discomfort they expect others to).

and the label the way they have implemented it tends to get used as an excuse to blame the person for breaking rather than the situation or lack of support in giving it from breaking them (which would be proper psychology)

this whole distress thing is of course a whole nother level of that issue and manipulating that weak flip over that happens between psychology and the medical own version of it (because they can’t diagnose ‘bad situation injury’ and pouring funds into prevention of that being made worse wouldn’t be going to a medical dept so… partly but there is more to it)

in this case it’s putting the foot on someone’s neck and doing everything else other than what would help whilst claiming you are trying I don’t know why they are still squealing ‘they must be distressed’ game. They get to prove their distress theory either by causing it or worse sometimes even if someone stays calm making up stories or describing what they’ve done to suggest to others ‘so they must be distressed’ .

All the time using that as an excuse to ignore and dismiss the issue that’s actually needing funding and looking into by someone else.

 

Note that the APA's DSM-5 was published in 2013. ICD-11's "Bodily distress disorder" was added to the ICD-11 Beta draft in 2012.

For ICD-11, Fibromyalgia was moved to the Symptoms chapter early on in the ICD-11 development process (in May 2015). UK and some international Fibro orgs were advised at the time.

These are not new developments. Bodily distress disorder and Somatic symptom disorder are also included in SNOMED CT terminology system.

Allen Frances¹, Suzy Chapman². DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. 1 Department of Psychiatry, Duke University 2 DxRevisionWatch.com
Aust N Z J Psychiatry. 2013 May;47(5):483-4. doi: 10.1177/0004867413484525 http://www.ncbi.nlm.nih.gov/pubmed/23653063

In collaboration with Professor Allen Frances, chair of DSM-IV task force:

Frances A. DSM-5 Somatic Symptom Disorder. J Nerv Ment Dis. 2013 Jun;201(6):530-1. doi: 10.1097/NMD.0b013e318294827c http://www.ncbi.nlm.nih.gov/pubmed/23719325

Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013 Mar 18;346:f1580. doi: 10.1136/bmj.f1580 http://www.ncbi.nlm.nih.gov/pubmed/23511949


I was responsible for having exclusions for the 8E49 terms:

Postviral fatigue syndrome(8E49)
Chronic fatigue syndrome(8E49)
Myalgic encephalomyelitis(8E49)

inserted under ICD-11's Bodily distress disorder. This proposal was approved and implemented in January 2020: https://icd.who.int/browse/2024-01/mms/en#767044268

 

Comparison of SSD, BDD, BDS and BSS in classification systems v2 Version 2 | November 2020: minor text revisions; revised links; updates on outcome of ICD-11 proposals Version 1 | July 2018

Document prepared by Suzy Chapman (DxRevisionWatch.com) and Mary Dimmock to assist stakeholders in navigating the complexities of disorder nomenclature and classification.

https://dxrevisionwatch.com/wp-cont...dd-bds-bss-in-classification-systems-v2-1.pdf