Bodily distress disorder

Bodily Distress Disorder (BDD) is a diagnosis which might be given to an individual who experiences distress due to persistent or recurrent bodily symptoms, to the degree the distress and preoccupation with symptoms interferes with daily functioning. It is coded in the International Classification of Diseases (ICD-11) chapter for Mental, Behavioural and Developmental Disorders under the code 6C20 (WHO 2022). The most common bodily symptoms associated with Bodily Distress Disorder include pain (e.g., musculoskeletal pain, backache, headaches), fatigue, gastrointestinal and respiratory symptoms, although patients may suffer from any bodily symptoms.

Experiencing symptoms and being concerned about them is of course a normal human experience. To meet criteria for a diagnosis of Bodily Distress Disorder, the individual must experience a characteristic pattern of thoughts, feelings and behaviours related to their health concerns, which contributes to distress, and a disruption in functioning. Assigning a Bodily Distress Disorder diagnosis would indicate that the patient might benefit from some psychological or behavioural interventions to improve their quality of life, regardless of the underlying cause of their symptom(s). Unlike in previous iterations of the diagnosis, in Bodily Distress Disorder, symptoms are not ‘medically unexplained’ (i.e. they may occur alongside disease). Bodily distress disorder can affect anyone at any age and the emergence of symptoms in any individual is underpinned by a complex interplay of biological, psychological and social factors.

Bodily Distress Disorder should not be confused with Body Dysmorphic Disorder (ICD-11 6B21) as the same acronym ‘BDD’ are sometimes used for both conditions.

Essential (Required) Features listed in the ICD-11 are:

1. The presence of bodily symptoms that are distressing to the individual. Typically, this involves multiple bodily symptoms that may vary over time. Occasionally the focus is limited to a single symptom, usually pain or fatigue.

2. Excessive attention is directed toward the symptoms, which may manifest in:

o    Persistent preoccupation with the severity of the symptoms or their negative consequences. In individuals who have an established medical condition that may be causing or contributing to the symptoms, the degree of attention related to the symptoms is clearly excessive in relation to the nature and severity of the medical condition.

o    Repeated contacts with health care providers related to the bodily symptoms that are substantially in excess of what would be considered medically necessary.

3. Excessive attention to the bodily symptoms persists despite appropriate clinical examination and investigations or appropriate reassurance by health care providers.

4. Bodily symptoms are persistent; that is, some symptoms are present (though not necessarily the same symptoms) on most days during a period of at least several months (e.g., 3 months or more).

5. The bodily symptoms and related distress and preoccupation result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

6. The symptoms or the associated distress and preoccupation are not better accounted for by another mental disorder (e.g., Schizophrenia or Other Primary Psychotic Disorder, a Mood Disorder, or an Anxiety or Fear-Related Disorder).

BDD can be assigned as mild (6C20.0) Moderate (6C20.1) or Severe (6C20.2) depending on the degree and impact of the features listed above.

The term ‘bodily distress’ was introduced in 2005 after research in Denmark suggested that an umbrella term was able to adequately capture a number of overlapping functional somatic syndromes as well as ‘Somatoform disorder’ (Fink et al. 2005). Bodily Distress Syndrome was conceived as this umbrella term for several diagnosable patterns of physical symptoms, thought to relate to patterns of physiological stress responses. The concept had the benefit of being derived clearly from empirical studies and validated, whereas many competing concepts were derived by consensus or through a process of cultural construction, which helped it to appeal to the ICD-11 committee (Rief and Isaac, 2014). However the ICD-11 concept of BDD ultimately developed, to be more aligned with the DSM-5 diagnosis: Somatic Symptom Disorder, with the need for positive psychological findings, and without the requirement that symptoms were medically unexplained.

The term Bodily Distress Disorder replaces the old category ‘somatoform disorders’ used in ICD-10. In the DSM-5 the concept of somatoform disorders has been replaced by the concept ‘Somatic Symptom Disorder’ (APA 2013).

Another important change in the new criteria is they allow for BDD to exist with any somatic/physical illness. These changes are considered a progressive move towards understanding the individual in more holistic terms, away from unhelpful dichotomies of body and mind, or “mental versus physical”; and to allow the diagnosis to be assigned more easily where there are coexisting medical problems, allowing the patient to access proper treatment. Despite these changes being cautiously welcomed, terminology in this area has a long history of being used in problematic and stigmatising ways. There remain concerns that the diagnosis of Bodily Distress Disorder could be used to label the ‘difficult patient’ or to bias the clinician against appropriate investigation of structural disease that could be contributing to symptoms in people diagnosed with BDD.

Due to this being a new diagnostic concept, more research is needed to determine how prevalent BDD is. 

A common model used in healthcare to help explain the onset and course of disease involves looking at predisposing, precipitating (triggering) and perpetuating (maintaining factors).  Emerging research highlights the importance of an individual’s “expectations of symptoms'' as having a central role. Having certain illness expectations based on prior experience could be influenced further by emotional states in someone who has a tendency to catastrophise (think the worst) or who is prone to illness anxiety. This could lead to the development and continuation of persistent somatic symptoms. The power of expectations to predict symptom course and treatment has been shown in many conditions such as pain, rheumatoid arthritis, cancer, and so called “medically unexplained symptoms”; and addressing patient expectations about symptoms has been shown to improve outcomes and potentially help individuals with these problems (Löwe et al., 2022). 

The diagnosis of Bodily Distress Disorder (BDD) is usually made in the healthcare setting most often by a doctor – this could be a primary care physician, hospital physician, liaison psychiatrist or other specialist in the area of psychosomatic medicine. The primary care physician or family doctor will generally play an important role in coordinating treatment with a secondary care clinician if necessary. The diagnosis of BDD is essentially clinical, whereby the clinician undertakes a thorough medical and mental health history and relevant examinations. Diagnosis is based on the nature of the presenting symptoms, and is a “rule in” as opposed to “rule out” diagnosis - this means it is based on the presence of positive symptoms and signs that follow a characteristic pattern described above. There are no tests that can consistently be used to diagnose BDD; however, as is the case with all diagnoses, often additional diagnostic tests such as blood tests or diagnostic imaging will be undertaken to consider the presence of underlying disease. BDD can coexist with any other diagnosis, (such as respiratory disease or cancer, or other mental health diagnoses as above).

Those preoccupied with the possibility of having serious or life-threatening illnesses, could better fit the diagnosis “Health anxiety disorder”. Individuals with Health anxiety disorder may also seek medical attention, but their primary purpose is to obtain reassurance that they do not have the feared serious medical condition. Individuals with Bodily Distress Disorder typically seek medical attention in order to get relief from their symptoms, not to disconfirm the belief that they have a serious medical illness.

 It is important to identify mood disorders, such as depression, where somatic symptoms (including weight loss, fatigue and pain) are often dominant aspects of the clinical presentation. Panic disorder and generalised anxiety disorder are also important differential diagnoses.

Underlying medical conditions or diseases must of course also be considered and treated appropriately. The patient might also meet criteria for functional somatic syndrome diagnostic categories such as fatigue related syndromes (8E49), dissociative disorders (6B60-6B6Z), chronic widespread pain (MG30.01) or irritable bowel syndrome (DD91).

The course of Bodily Distress Disorder (BDD) is variable. In about half of individuals diagnosed with Bodily Distress Disorder seen in primary care settings, bodily symptoms resolve within 6 to 12 months (Rask et al 2017.). Individuals with severe disorder and those with multiple bodily symptoms tend to experience a more chronic and persistent course. The presence of multiple bodily symptoms is commonly associated with greater impairment in functioning as well as with poorer treatment response for any co-occurring mental or medical conditions. Research is growing in this area, and it is hoped that the implementation of robust science driven research will allow effective supports for individuals with BDD to develop.

Once the person receives a diagnosis, the goal of treatment is to help the patient manage their symptoms and achieve a better quality of life. There are established self-help approaches patients can try, which include pacing, stress management and thinking about how the environment could better support return to a state of health. As is the case with any illness, healthy lifestyle measures such as maintaining regular physical activity, sleep hygiene, engagement with social activities and outlets/hobbies are helpful, but may need to be reintroduced slowly if the person has been avoiding these activities. Medication can be helpful to manage symptoms where significant depression, anxiety or pain is an issue.

Understanding and accepting the diagnosis is usually an important aim, as it will be difficult for a person to begin to shift their focus towards recovery if they continue to worry that they have the wrong diagnosis. Repeated investigations are not always necessary or reassuring; open conversations between the patient and their doctor which include plausible explanations for common symptoms and the risk of any potential rare causes is usually a more helpful approach. When healthcare professionals are giving a diagnosis and carrying out treatment, it is important to communicate openly and honestly and not to fall into the trap of dualistic – that is “either mental or physical” thinking; or attempt to “reattribute” symptoms to a predominantly psychosocial cause. The diagnostic process is considered an important step in order for treatment to move forward successfully (Henningsen et al 2022).

Specialist treatment for BDD is unfortunately still rare in many countries. Gold-standard treatment should take a holistic patient-centred approach, tailored for an individual’s specific needs. The specific therapeutic approach taken will likely depend on the nature of the symptoms and what might be driving them, and usually involves one or more members of a multidisciplinary therapeutic team. Psychotherapy such as Cognitive Behavioural Therapy or Acceptance and Commitment Therapy might be helpful to explore a pattern of thoughts, actions and behaviours that could be driving a negative cycle that maintains the symptoms. Physiotherapy may be relevant for rehabilitation when weakness, pain, dizziness or fatigue is a problem. In some cases, it can be helpful to liaise with other caregivers such as family/partner to support the individual in their rehabilitation.

For some patients, especially those who have lived with the symptoms for many years, realistic treatment includes a focus on management of symptoms and improvements in quality of life. Acceptance of symptoms and the limitations they cause can be key in these situations, but most people are able to see some improvement in their condition. Open and trusting relationships with the healthcare team are key to this.

For many years there has been an unhelpful divide in the medical system between ‘mental’ and ‘physical’ disease, that stems from mind-body dualism. Although it is increasingly recognised that most medical conditions involve a complex interaction of physical, experiential, and social factors, there is still an old-fashioned view in many parts of society that patients experiencing BDD (and its diagnostic predecessors) have a purely psychological problem, which is associated with stigma.

Many mental health services do not consider problems with somatic symptoms to be in their remit, and since BDD falls between medical and psychiatric parts of health services, those conditions like BDD, where mental and physical factors are inter-related and similarly important, are often neglected. A lack of appropriate treatment services also exacerbates stigma, and many people who suffer from these conditions report negative experiences with the healthcare system. They have also been labelled as ‘heart-sink patients’ by some doctors, who feel inadequately equipped to help them, again partly due to lack of specialist treatment services, and in part due to an exclusion of these types of disorders from medical training.

Due to these controversies and stigma within the health service, the terminology used to describe these disorders and diagnostic classifications continue to evolve. This ever-changing terminology can be confusing for both clinicians and patients, and in itself gets in the way of these conditions being better understood.  Bodily Distress Disorder has been criticised on a number of counts. There are some who feel that the word ‘Distress’ itself is stigmatising as it could be used to pathologise an understandable response to physical suffering. Others have concerns that description of the diagnosis is too subjective and normative – i.e. who is it to say that a worry about a symptom is ‘excessive’? This leads to concerns the diagnosis could be used to pathologise a way of interacting with the healthcare system which the doctor considers inappropriate or otherwise problematic (Gureje and Reed 2016).   

Another problem with the diagnosis is captured by the structure of the diagnostic manuals themselves. ICD-11 has separate chapters for mental and physical conditions, again reflecting the dichotomous structure of the medical system and mind-body dualism. However, this probably leads to the diagnosis being under-used as most patients with somatic symptoms are seen by doctors without expertise in mental health and who may not therefore consider the diagnosis. In reality these conditions fit between physical and mental health categories, but must currently usually attract two separate diagnoses-one physical and one mental, which might be describing the same phenomenon. Others consider this a reasonable solution, especially as there are distinct psychological features of BDD which are not present in all patients with persistent physical symptoms and may therefore require additional support. In many health systems, having a distinct diagnostic code can be helpful to allow patients to access these specific treatments.

 APA., 2022. Diagnostic and Statistical Manual of Mental Disorders. Washington: American Psychiatric Publications Inc.

Fink, P., et al. ‘Symptoms and Syndromes of Bodily Distress. An Explorative Study among 978 Internal Medical, Neurological and Primary Care Patients’. Submitted 2005, vol. Submitted April 05, no. Journal Article, 2005.

Gureje, Oye, and Geoffrey M. Reed. ‘Bodily Distress Disorder in ICD‐11: Problems and Prospects’. World Psychiatry, vol. 15, no. 3, Oct. 2016, p. 291. www.ncbi.nlm.nih.gov, https://doi.org/10.1002/wps.20353.

Henningsen, P. (2022). Management of somatic symptom disorder. Dialogues in clinical neuroscience.

Löwe, B., Levenson, J., Depping, M.et al., (2022). Somatic symptom disorder: A scoping review on the empirical evidence of a new diagnosis. Psychological Medicine 52:632-48

Mary Dimmock and Suzy Chapman (DxRevisionWatch.com) t. Comparison of SSD, BDD, BDS, BSS in Classification Systems. https://dxrevisionwatch.files.wordpress.com/2018/07/comparison-of-ssd-bdd-bds-bss-in-classification-systems-v1.pdf.

Rask, Mette Trollund, et al. ‘Long-Term Outcome of Bodily Distress Syndrome in Primary Care: A Follow-Up Study on Health Care Costs, Work Disability, and Self-Rated Health’. Psychosomatic Medicine, vol. 79, no. 3, Apr. 2017, pp. 345–57. journals.lww.com, https://doi.org/10.1097/PSY.0000000000000405.

Rief, Winfried, and Mohan Isaac. ‘The Future of Somatoform Disorders: Somatic Symptom Disorder, Bodily Distress Disorder or Functional Syndromes?’ Current Opinion in Psychiatry, vol. 27, no. 5, Sept. 2014, pp. 315–19. journals.lww.com, https://doi.org/10.1097/YCO.0000000000000089.

WHO. SCAN. Schedules for Clinical Assessment in Neuropsychiatry, Version 2.1. World Health Organization, Division of Mental Health, 1998.

WHO 2022 Icd.who.int. ICD-11. [online] Available at: <https://icd.who.int/en> [Accessed 29 May 2022].

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Acknowledgement: This text has been developed within the ETUDE innovation training network and will be used for publication on international Wikipedia pages.