On the misdiagnosis of somatization disorder in Gulf War veterans and others with overlapping disorders of Chronic Fatigue, Fibromyalgia and Multiple Chemical Sensitivity.

26 February 1996

Albert Donnay, MHS, Executive Director
MCS Referral & Resources, Inc.
2326 Pickwick Rd, Baltimore MD 21207-6631
410-448-3319, donnaya@rtk.net

Many Gulf War veterans with otherwise "unexplained" illness are being given the psychogenic diagnosis of "SOMATIZATION DISORDER" by DoD and VA physicians. According to Stedman's Medical Dictionary, somatization means the "the conversion of anxiety into physical symptoms" (1972 edition, p.1163).

In practice, the diagnosis is supposed to be given only to patients who report at least 13 of the 35 specific subjective symptoms for which no physical evidence or medical explanation can be found. The list given below is from the somatization section of the standard Diagnostic Interview Survey-III-A and also appears in the ICD-9CM diagnostic coding manual. The items shown in italics (*) are the seven most common which are recommended for initial screening.

Symptoms of Somatization Disorder

- Diagnosis requires 13 or more that lack an acceptable medical explanation(s).

- The 7 symptoms in italics (*) are recommended for initial screening.

- If patient record offers evidence or an explanation for a symptom, it should not be counted.

1. Vomiting (other than pregnancy)
2. * Pain in extremities
3. *Shortness of Breath
4. Deafness
5. Trouble walking
6. Abdominal Pain
7. Back pain
8. Palpitation
9. Double Vision
10. Muscle weakness
11. Nausea
12. Joint pain
13. Dizziness
14. Blurred Vision
15. Difficulty urinating
16. Bloating
17. Pain during urination
18. * Amnesia
19. Blindness
20. * Burning sensation in sexual organs or rectum other than during sex
21. Diarrhea
22. Other pain excluding headaches
23. * Difficulty Swallowing
24. Fainting/loss of consciousness
25. Sexual indifference
26. Intolerance of different foods
27. Chest Pain
28. Loss of voice
29. Seizure or convulsion
30. Pain during sex

For Women Only:

1. * Painful menstruation
2. Irregular periods
3. Execssive menstrual bleeding
4. Vomiting throughout pregnancy.

Of the Gulf War veterans' Top 10 reported symptoms, only 3 are listed among these 35: joint paint, other (muscle) pain, and diarrhea.

Veterans who feel they have been given a diagnosis of somatization disorder incorrectly and wish to do something about it are urged to contact MCS Referral & Resources for assistance.

Given the overlap between symptoms of Gulf War Syndrome and the syndromes of Chronic Fatigue, Fibromyalgia, and Multiple Chemical Sensitivity, 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.