Psychosomatics 2012:53:524 531

2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Perspectives
The DSM 5 Website Proposals for Somatic Symptom
Disorder: Three Central Problems
Richard Sykes, Ph.D., C.Q.S.W.

he DSM 5 Workgroup on Somatic Symptom Disorders (SSDs) has shown a welcome openness in making public their deliberations, both in their published Interim proposals1 and on the DSM 5 Website.2,3 While this
and a previous paper4 are critical of some central points in
their proposals, both papers are intended to be positive
contributions towards resolving a difficult problem.
Bryson5 has observed that Taxonomy is described sometimes as an art and sometimes as a science, but really its
a battleground (p 437). But despite this gloomy assessment, I hope that this present paper and the previous
paper4 will help to generate more light than heat on a
difficult problem.
OUTLINE OF PAPER
The DSM-IV-TR account of somatoform disorders6 has
met with a wide range of objections from many critics,714 including important critiques by the CISSD
(Conceptual Issues in Somatoform and Similar Disorders) project,7 by Mayou et al,8 and by Fava et al.9 This
paper, however, like the previous paper4 to which it is
a sequel, focuses on some central conceptual problems.
It first summarizes the argument of the previous paper.4
It then identifies three central problems and asks
whether these problems have been successfully resolved
by the Website proposals, either by the earlier version
(posted April 2011)2 or by the later version (posted
April 2012).3 The three central problems are: (1) the
ambiguity in the classification of specialty syndromes, (2) the lack of an adequate justification for
classifying SSDs as mental disorder, and (3) the lack of
an adequate unifying principle for SSD. The paper notes
that advances are made by both the earlier and the later
Website proposals but argues that no satisfactory answers to the three central problems are provided by
either set of Website proposals.
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The paper then raises a concern that although the

Website proposals appear to have dispensed with the feature of medically unexplained physical symptoms as a
criterion of SSD, this feature may not, in fact, have been
dispensed with but is still being used and has merely been
concealed. It is then suggested that the feature of medically unexplained physical symptoms may better be regarded as the basis for a preliminary grouping of disorders
for further differential diagnosis, rather than as the basis
for a formal category of mental disorder. It concludes by
recommending that the category of somatoform disorder
or SSD is best dispensed with, as many critics have
argued.714
As with the previous paper, the focus of this paper is
on conceptual issues. This is not to undervalue the importance of empirical studies such as those by Kroenke,15 for
example, which show that the simple unexplained complaint is poorly recalled, or studies such as those by Simon
and Gureje,16 which show that conditions now classified
as somatization disorders have a chronic course. But conceptual issues are of equal value and sometimes do not
receive sufficient attention.

SUMMARY OF PREVIOUS PAPER

The previous paper4 set out two central issues for the
DSM-IV-TR account of somatoform disorder6 and asked
whether the DSM 5 Workgroups published Interim proposals1 provided a satisfactory resolution of these probReceived April 12, 2012; revised June 7, 2012; accepted June 8, 2012. From
Associate, Institute of Psychiatry, Kings College London, Health Services Research, London, UK. Send correspondence and reprint requests
to Richard Sykes, Ph.D., C.Q.S.W., I5 Queen Victoria Road, Bristol BS6
7PE, UK; e-mail: richardsykes@blueyonder.co.uk
2012 The Academy of Psychosomatic Medicine. Published by
Elsevier Inc. All rights reserved.

Psychosomatics 53:6, November-December 2012

Sykes
lems. It argued that some important advances had been
made but that these were offset by four serious difficulties.
The two central issues identified in the earlier paper
are, first, the ambiguity in the classification of syndromes such as Irritable Bowel Syndrome (IBS), and
Fibromyalgia (FM). Such syndromes are found in most
medical specialties, e.g., IBS in gastroenterology, FM
in rheumatology, and will be referred to here as specialty syndromes. (Although the term functional is
commonly used to refer to such syndromes (see
e.g.,17,18), it can carry the implication of psychogenic19 and will be avoided here). The second central
problem is the unsuitability of the unifying principle for
the category of somatoform disorderthe feature of
physical symptoms that are medically unexplained.
(Note: the term medically unexplained physical symptoms will be used in this paper to include physical
symptoms that are not fully medically explained.)
The previous paper agreed that the Workgroups
Interim proposals had made progress towards the resolution of these problems. They had recognized calls for
positive psychological criteria for SSD. Secondly, they
had provided a conceptual framework, which proposed
dual diagnosis for some kinds of specialty syndromes
but not for others. This framework had the potential to
resolve the ambiguity in the classification of specialty
syndromes. Thirdly, they had eliminated any requirement that the physical symptoms of SSDs should be
medically unexplained.
But the Interim proposals still faced four major
problems. In the first place, the ambiguity in the classification of specialty syndromes still remains. The advantages of the conceptual framework proposed had not
been fully utilized because the psychological criterion
provided for SSD (psychological factors may (my underlining) initiate, exacerbate, or maintain these symptoms) is too weak to distinguish between different
types of specialty syndromes, for all specialty syndromes satisfy that criterion. Secondly, the psychological criterion provided is also too weak to justify the
classification of SSD as a mental disorder, for it is also
true of the symptoms of general medical conditions as
well that psychological factors may (my underlining)
initiate, exacerbate, or maintain these symptoms.
Thirdly, the natural consequence of abandoning the feature of medically unexplained physical symptoms as a
unifying principle for the category is to dissolve the
category. Finally, no satisfactory alternative unifying
principle for SSD had been provided, for both the soPsychosomatics 53:6, November-December 2012

matic and the psychological criteria proposed are too

weak to be effective.
THREE CENTRAL PROBLEMS
This paper identifies a third central problem in addition to
the two identified in the previous paper. The resulting
three central problems are: (1) the ambiguity in the classification of specialty syndromes, (2) the lack of an adequate justification for classifying SSDs as mental disorders, and (3) the lack of an adequate unifying principle for
SSD. The paper asks whether the Website proposals, either the earlier or the later version, are more successful
than the Interim proposals in finding adequate answers to
these three central problems. The earlier Website proposals are considered first.
THE EARLIER WEBSITE PROPOSALS (APRIL 2011)
Significant Advances
As with the Interim proposals, three significant advances have been made by the earlier Website proposals:
(a) Recognition of the calls for positive psychological
criteria for SSDs.
(b) Provision of a strong conceptual framework for resolving the ambiguity in the classification of specialty
syndromes. Implicit in this framework is the classification of specialty syndromes as general medical conditions. If they also satisfy criteria for SSD, they are to
be given a dual classification, both as general medical
conditions and as SSD.
(c) Elimination of any requirement that the physical
symptoms of SSDs should be medically
unexplained.
BUT HAVE THE EARLIER WEBSITE PROPOSALS
BEEN MORE SUCCESSFUL THAN THE INTERIM
PROPOSALS IN DEALING WITH THE THREE
CENTRAL PROBLEMS?
Central Problem 1Ambiguity in the Classification
of Specialty Syndromes
The Interim proposals introduced a conceptual framework that has the potential to resolve the ambiguity in the
classification of specialty syndromes. As noted above, and
in the previous paper,4 this conceptual framework allows
for dual classification of specialty syndromes if they also
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Somatic Symptom Disorder: Three Central Problems

satisfy criteria for SSD. However, the advantages of this
conceptual framework are nullified by the weakness of the
psychological criterion that the Interim proposals provided
for SSD, psychological factors may initiate, exacerbate,
or maintain the symptoms. This psychological criterion,
as argued in the previous paper,4 is too weak to distinguish
effectively between specialty syndromes because all specialty syndromes satisfy the criterion. Hence the ambiguity
in the classification of specialty syndromes still remains.
The earlier Website proposals face the same difficulty. In the earlier Website proposals, the psychological
criterion in the general account of SSD is also too weak to
distinguish between specialty syndromes. It is the weak
criterion that symptoms may be initiated, exacerbated, or
maintained by combinations of biological, psychological,
and social factors. This differs from the unsatisfactory
criterion of the Interim proposals only in that it is presented in the passive voice rather than the active voice and
that it includes biological and social factors as well as
psychological factors. But these minor changes still leave
the fundamental weakness that the criterion does not effectively distinguish between specialty syndromes. For all
cases of specialty syndromes satisfy the criterion. Hence,
as with the Interim proposals, the ambiguity in the classification of specialty syndromes still remains.
As with the Interim proposals, a major problem with
this criterion is the inclusion of the word may. As argued
in the earlier paper,4 if the word may had been omitted,
the clause would read psychological factors initiate, exacerbate, or maintain these symptoms; this would place a
requirement on the doctor to have some evidence that a
relevant psychological factor is present and that this factor
has a causal influence on the disorder. This would provide
a means of distinguishing between different kinds of specialty syndromes, for in some cases of specialty syndromes there would be evidence that such a causal factor
is present; in others there would be no such evidence.
The absence of a strong psychological criterion in
the general account of SSD means that there is no requirement that such a strong criterion be provided for all the
subcategories. While such strong psychological criteria are
provided for some subcategories (e.g., for Complex and
Simple SSD) in both the Interim and the earlier Website
proposals, there are other subcategories in which there is
no mention of such strong psychological criteria. This
deficiency is particularly acute for the earlier Website
residual categories of Other Specified SSD and unspecified SSD (as it is for the DSM-IV-TR subcategories
of Undifferentiated Somatoform Disorder and of Somato526

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form Disorder Not Otherwise Specified). Both of these

key subcategories are left undefined in the earlier Website
proposals. Hence, there is no assurance that in the final
version these residual subcategories will contain strong
positive psychological criteria. Indeed, it seems likely that
they will not contain such criteria, for if such strong criteria are intended to be included in the final proposals for
these residual subcategories, one would have expected
such strong criteria to be included in the general account
of SSD as well.
Hence, the ambiguity in the classification of specialty
syndromes has not been resolved.
Central Problem 2Inadequate Justification for the
Classification of SSD as a Mental Disorder
As with the Interim proposals, the psychological criterion proposed in the earlier Website proposals2 is too
weak to justify the classification of SSDs as mental disorders. The psychological criterion has been changed, as
noted earlier, to the requirement that the physical symptoms may be initiated, exacerbated, or maintained by
combinations of biological, psychological, and social factors; but many general medical conditions also satisfy
this criterion.20,21 As with the Interim proposals, the crucial weakness is the use of the word may. Hence, the
earlier Website proposals also fail to provide justification
for classifying SSDs as mental disorders.
Central Problem 3Inadequate Unifying
Principle for SSD
As with the Interim proposals, the Workgroup has
abandoned the unifying principle of having physical
symptoms that are medically unexplained, but has not put
any adequate unifying principle in its place. The natural
consequence of abandoning the unifying principle for a
category is to dissolve the category, as argued in the
previous paper.4
THE LATER (APRIL 2012) WEBSITE
PPROPOSALSSOME CHANGES AND
INITIAL COMMENTS
There are several changes in the later Website proposals of
which five will be singled out for comment.
One difference between the earlier and the later (April
2012) proposals is the abolition of the distinction between
the subcategories of Complex and Simple SSD and the
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Sykes
replacement of these two subcategories by the single subcategory of SSD.
The reason for this revision appears to be provided in
a criticism by Michael First. First22 has argued that the
distinction drawn in the Website proposals between Complex and Simple SSD is unacceptable. One of the differences between Complex and Simple SSD is that whereas
Complex SSD requires that the patient satisfy two of the
three items for the B criterion, Simple SSD requires that
the patient satisfy only one. First has pointed out that the
three items in criterion B are not independent of each other
and conceptually blur into one another. He asks how a
patient could qualify for having disproportionate and persistent concerns about the medical seriousness of ones
symptoms (item B1), without also having a high level of
health related anxiety (item B2). He argues that consequently one of the distinctions between Complex and Simple SSD would not be possible to make reliably in practice.
This objection seems to be well founded. It also reinforces the point that conceptual clarity is fully as important as field trials and that without conceptual clarity, field
trials can be unproductive as well as expensive.
A second change is that the same term SSD is now
used both as the name of the main category and as the
name of one of the subcategories, the single subcategory
which replaces the subcategories Complex SSD and Simple SSD. This use of the same term as the name for two
different things seems to invite confusion.
A third change is that the single subcategory SSD
Not Elsewhere Classified replaces the two former subcategories Other Specified SSD and Unspecified
SSD.
A fourth change is that in the general account of the
main category SSD, there is no requirement that there
should be any psychological criterion at all. The requirement for SSDs is that they all involve presentation of
physical symptoms and/or concern about medical illness.
The and/or connection means that even the extremely
weak psychological criterion of concern about medical
illness is not necessary, and that presentation of physical
symptoms is enough. But what patient with a serious general medical condition would not present physical symptoms (or indeed show a concern about medical illness)?
Even the weak psychological criterion previously provided is omitted. This means that the account of the main
category is far too broad as it stands. It allows the possibility that the residual subcategory, SSD Not Elsewhere
Classified, could include conditions that did not satisfy any
Psychosomatics 53:6, November-December 2012

psychological criterion at all. At present, only pseudocyesis is listed under this subcategory, but theoretically, conditions that did not satisfy any psychological criterion (and
so did not have any adequate claim to be classed as mental
illnesses) could also be included here.
A fifth change is the definite inclusion of Factitious
Disorder as a subcategory of SSD. (In the earlier Website
proposals, this had just been mentioned as a possibility.)
THE LATER (APRIL 2012) WEBSITE PROPOSALS
AND THE THREE CENTRAL PROBLEMS
Are the later Website proposals3 more successful than the
earlier proposals2 in providing satisfactory answers to the
three central problems?
Central Problem 1Ambiguity in the Classification
of Specialty Syndromes
The ambiguity in the classification of specialty syndromes still remains. For the later Website proposals provide no psychological criterion at all for the main category
SSD.
This point is obscured by the ambiguity of the term
SSD as pointed out above. It is true that the subcategory
SSD does contain a strong psychological criterion, but no
psychological criterion at all is provided for the main
category SSD. This allows the possibility that the subcategory, SSD not Elsewhere Classified, which at present is
left undefined, may not be given a sufficiently strong psychological criterion or, indeed, any psychological criterion
at all when the final version for DSM-5 is produced. (Such
a subcategory would be comparable to the DSM-IV-TR
subcategories of Undifferentiated Somatoform Disorder
and Somatoform Disorder Not Otherwise Specified for
which no psychological criteria are provided.) The result
of this would be that all specialty syndromes could be
classified as SSDs as well as general medical conditions
and the ambiguity in the classification of specialty syndromes would still remain.
Central Problem 2Lack of Adequate Justification
for Classifying SSDs as Mental Disorders
The later Website proposals are not more successful
than the earlier ones in providing a justification for classifying SSDs as mental disorders. This point is again obscured by the use of the same term SSD to name both
the main category and one of the subcategories. It is true
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Somatic Symptom Disorder: Three Central Problems

that psychological criteria have been provided for the subcategory SSD, but no psychological criteria at all have
been provided for the main category SSD. Without psychological criteria, such a category would lack justification
for being classified as a mental disorder. As argued above,
it could contain subcategories that also did not contain
psychological criteria and that also would lack justification
for being classified as mental disorders.

Central Problem 3Lack of Adequate Unifying

Principle for the Main Category SSD
The absence in the later Website proposals of any
psychological criterion for the main category SSD, coupled with the absence of the DSM-IV-TR criterion that the
physical symptoms should be medically unexplained, also
means that the category lacks any adequate unifying principle. The unifying principle for the category has been
given up, but no adequate replacement criterion has been
provided.
The problem of finding an adequate unifying principle
for the category of SSD is made even harder by the confirmed inclusion of Factitious Disorders among SSDs. (In
the earlier Website proposals, this had just been mentioned
as a possibility.) The rationale provided for this is that it
would help physicians with the differential diagnosis of
patients who present with persistent problems of illness
perception, frequently including unexpected and/or unexplained psychological and/or physical symptoms.
But this gives rise to at least three problems. In the
first place, it suggests that all patients with SSDs have
persistent problems with illness perception. This is a much
stronger criterion than any criterion proposed in the general account of the main category SSD and is not consistent with that account. Secondly, the inclusion of Factitious Disorder introduces an extra dimensionthat of
feigning symptomsand makes the category SSD even
more of a miscellaneous category. But, in general, the
larger the miscellaneous section of a classification, the
less good the classification. Thirdly, the inclusion of
Factitious Disorder is likely to add to the stigma already
associated with the category and consequently risks the
alienation of patients.
Hence the later (April 2012) Website proposals are no
more successful than the earlier (April 2011) proposals.
Both sets of proposals fail to provide adequate answers to
the three central problems identified.
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A Covert Use of Medically Unexplained?

In the Interim proposals and in both sets of Website
proposals, the Workgroup claims to have de-emphasised
the role of medically unexplained physical symptoms in
their account of SSD. In support of this claim, they can
point to the fact that this feature is not mentioned in their
account of SSD and that SSD can be diagnosed even when
medical disease is present. But what does this de-emphasis amount to and what is its cost?
In what follows, I argue that the cost of this deemphasis is a crucially flawed account of the category of
SSD, and that this feature has not in fact been eliminated
but is hidden from view and is implicitly presupposed.
There are three grounds for this concern. In the first
place, the criterion of medically unexplained physical
symptoms has been omitted from the general account of
the main category SSD that is given in the Interim proposals, and in both the earlier and later Website proposals.
But the result of this is that the account given of the main
category SSD is far too broad as it stands. It allows the
inclusion of many other conditions besides those selected
as subcategories of SSD. (As argued above, the psychological criterion for the main category SSD in the Interim
and the earlier Website proposals is too weak, and in the
later Website proposals no psychological criterion at all is
provided for the main category SSD.) Hence, if taken at
face value, all specialty syndromes and, indeed, all general
medical conditions would be included. It only seems plausible if there is some tacit, unacknowledged assumption
that it only applies when there are physical symptoms
present that are not fully explained medically.
Secondly, a covert use of medically unexplained
appears to be apparent in the choice of the conditions that
are selected as the subcategories of SSD. All these subcategoriesthe subcategory SSD, Illness Anxiety Disorder etc.appear to be characterized by medically unexplained physical symptoms or by physical symptoms that
are not fully explained medically. It is difficult to believe
that this is just a chance characteristic.
One defense against the imputation that the feature
of having medically unexplained physical symptoms is
covertly implied might be to point out, as the Workgroup has done in the Interim proposals and in both sets
of Website proposals, that the diagnosis of an SSD can
be made even where a recognized medical disease is
present. Hence, it could be argued that the presence of
medically unexplained symptoms is not a necessary
feature of SSDs.
Psychosomatics 53:6, November-December 2012

Sykes
But this defense is not successful. Consider those
cases of general medical conditions where a supplementary diagnosis of SSD is made. In these cases, it is typically the case that it is the presence of medically unexplained physical symptoms that justify the additional
diagnosis of SSD. For example, if a doctor judges that a
male patient with an ankle injury also qualifies for a diagnosis of SSD as well as the diagnosis of the ankle injury,
the basis for this judgement is frequently the prior judgement that no purely medical explanation would fully account for the degree of pain that the patient seems to
exhibit. The doctor judges that medically unexplained
symptoms are also present and it is this judgement that is
the basis for giving a supplementary diagnosis of SSD.
A third cause for concern arises even in cases where
psychological features such as excessive concern are diagnosed and are used as the basis for a supplementary
diagnosis of SSD in addition to the diagnosis of a general
medical condition. In these cases, too, it will typically be
found that symptoms that are not fully explained medically are also present and that it is these additional symptoms that justify the judgement that the patients concern
is excessive and consequently the additional diagnosis of
an SSD. For example, if a doctor judges that a male patient
shows excessive concern for an injury to his ankle and so
qualifies for a diagnosis of SSD in addition to the diagnosis of an ankle injury, the basis for this judgement is
frequently the prior judgement that there is no medical
explanation that would fully account for the degree of pain
and concern that the patient seems to exhibit. The doctor
judges that the patients pain symptoms and pain behavior
are not fully explained by the ankle injury and it is this
judgement that is the basis for deciding that the patients
concern is excessive. Consequently, the judgement that the
patients symptoms are not fully medically explained has
not been eliminated but is just presupposed. It lies behind,
and provides the justification for, the judgement that the
patients concern is excessive.
These three considerations suggest that the Workgroup have recognized the problems in using the feature of
medically unexplained physical symptoms as the unifying
principle for a category of mental disorder and consequently have not made explicit use of it: but that instead of
accepting the natural consequence of this and dissolving
the category of somatoform disorder, they have continued
to make implicit use of it. It is there all the time, lurking
unacknowledged in the background.
Psychosomatics 53:6, November-December 2012

MEDICALLY UNEXPLAINED PHYSICAL

SYMPTOMS AS THE BASIS FOR PRELIMINARY
GROUPINGS OF DISORDERS, NOT FOR FORMAL
CATEGORIES OF MENTAL DISORDER
In the rationale for grouping Factitious Disorder together
with other SSDs (3), the Workgroup claims that this could
be a useful step for further differential diagnosis. While
this may be true, it is not in itself a sufficient ground for
making such a grouping into a formal category of mental
disorder.
In what follows, I will argue that the judgement that a
physical symptom in not fully explained medically can
be employed very usefully in a preliminary grouping of
disorders, but that it should not be used, either openly or
covertly, as a unifying principle for a formal category of
mental disorder.
In a preliminary grouping, disorders may be grouped
together for further differential diagnosis. Thus, presentations of red spots may usefully be grouped together for
further investigation and differential diagnosis. There is,
however, no formal category of diseases with red spots.
Other criteria, reflecting more fundamental differences,
are used for the formal categories of diseases into which
presentations of red spots are accommodated.
Similarly, a preliminary grouping of disorders with
medically unexplained physical symptoms may very usefully be made in order to facilitate differential diagnosis.
On further investigation, or as the condition develops,
these disorders can usefully be differentiated into well
established mental disorders, or disorders with subthreshold psychological features, or disorders with no significant
psychological features, or disorders where further physical
or psychological examination is called for, etc. But the
usefulness of the preliminary grouping does not in itself
provide sufficient justification for grouping such disorders
together as a formal category of mental disorder.
The Workgroup has ostensibly given up the criterion
of medically unexplained physical symptoms as the unifying principle for a category of mental disorders. They
are right to have done this for at least three reasons. In the
first place, there is the unreliability and provisional nature
of the judgement that a physical symptom is medically
unexplained or is not fully medically explained (see
e.g.,23). Secondly, the judgement that a physical symptom
is medically unexplained does not necessarily mean that
the symptom has a psychological cause. Such an inferencethe psychogenic inferenceis unacceptable for
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Somatic Symptom Disorder: Three Central Problems

historical, logical, scientific, and practical reasons, as argued elsewhere.9 Thirdly, the grouping cuts across the
fundamental division between general medical conditions
and mental disorders, for the grouping includes both general medical conditions and mental disorders.
The natural consequence of abandoning the unifying
principle of a category is to dissolve the category and to
reclassify the conditions that formed its subcategories
among other categories of physical and mental disorder.
But instead of accepting this and disbanding the category,
the Workgroup has attempted to retain, and indeed to
expand, the category. The result is the absence of any
satisfactory unifying principle and the resulting impression that the former unifying principle has been covertly
retained.
SUMMARY AND CONCLUSION
In common with the DSM-V Workgroups published Interim Proposals, both their earlier and their later Website
proposals fail to provide satisfactory solutions to three
central problems facing the DSM-IV-TR account of somatoform disorders. They fail to eliminate the ambiguity
in the classification of specialty syndromes, they fail to
provide adequate justification for classifying SSDs as
mental disorders, and they fail to provide a satisfactory
unifying principle for the category.
In addition, while the Interim and Website proposals
do not openly use the feature of physical symptoms that
are not fully medically explained as a unifying principle
for the main category SSD, there are concerns that this

feature may be covertly relied on in their account of the

main category.
Grouping together presentations of illness that are
characterised by the feature of medically unexplained
physical symptoms can be a very useful preliminary step
towards final diagnosis. However, as implicitly acknowledged by the Workgroups omission of this feature, it is
not a good basis for a formal category of mental disorder.
As mentioned in the earlier paper,3 decisions about
the future of somatoform disorder or SSD can have important practical implications. If the boundaries of the
disorder are unclear or are drawn too widely, this can
result in patients being given a diagnosis of mental disorder inappropriately. This can risk the alienation of patients. Patients quite naturally can be indignant if mental
disorder is ascribed to them inappropriately, for a diagnosis of mental disorder can bring stigma and serious practical disadvantages (see e.g.,11). An inappropriate diagnosis of mental disorder can also lead to inappropriate
treatment.
Neither the Interim nor the Website proposals provide
good reasons for retaining the category of somatoform
disorders, however named. There are strong reasons for
disbanding the category and for dispersing the constituent
subcategories, appropriately redefined, among other subcategories of mental disorder or of general medical conditions, as many critics7-14 have argued.
Disclosure: The author disclosed no proprietary or
commercial interest in any product mentioned or concept
discussed in this article.

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