Danger! Danger!…

Posted on Sunday 9 December 2012

Dr. Frances has added an addendum to his list of the ten worst ideas in the DSM-5:
Mislabeling Medical Illness As Mental Disorder
The eleventh DSM 5 mistake needs an eleventh hour correction
Psychology Today: DSM5 in Distress
by Allen J. Frances, M.D.
December 8, 2012

Many readers of my previous blog listing the ten worst suggestions in DSM 5 were shocked that I failed to mention an eleventh dangerous mistake – that DSM 5 will harm people who are medically ill by mislabeling their medical problems as mental disorder. They are absolutely right. I apologize for my previous failure to attend to this danger and hope it is not now too late to influence the process. Adding to the woes of the medically ill could be one of the biggest problems caused by DSM 5. It will do this in two ways: [1] by encouraging a quick jump to the erroneous conclusion that someone’s physical symptoms are ‘all in the head’; and [2] by mislabeling as mental disorders what are really just the normal emotional reactions that people understandably have in response to a medical illness. UK health advocate, Suzy Chapman, has closely monitored every step in the development of DSM 5. Her website is the best available resource for finding just about everything you need to know about DSM 5 and ICD-11. Ms Chapman sent me a troubling email that summarizes where DSM 5 has gone wrong and the many harmful consequences that will follow. More details are available at: ‘Somatic Symptom Disorder could capture millions more under mental health diagnosis‘ Ms. Chapman writes,

    "…The DSM-5 Somatic Symptom Disorders Work Group is planning to eliminate several little used DSM-IV Somatoform Disorders and replace them instead with an extremely broad new category that is likely to be wildly overused [‘Somatic Symptom Disorder’ – SSD]. "A person will meet the criteria for SSD by reporting just one bodily symptom that is distressing and/or disruptive to daily life and having just one of the following three reactions to it that persist for at least six months: [1] ‘disproportionate’ thoughts about the seriousness of their symptom<s>; or [2] a high level of anxiety about their health; or, [3] devoting excessive time and energy to symptoms or health concerns.

    "Unless DSM-5 changes these incredibly over inclusive criteria, it will greatly increase the rates of diagnosis of mental disorders in the medically ill – whether they have established diseases (like diabetes, coronary disease or cancer) or have unexplained medical conditions that so far have presented with somatic symptoms of unclear etiology. "The diagnosis of mental disorder will be based solely on the clinician’s subjective and fallible judgment that the patient’s life has become ‘subsumed’ with health concerns and preoccupations, or that the response to distressing somatic symptoms is ‘excessive’ or ‘disproportionate,’ or that the coping strategies to deal with the symptom are ‘maladaptive’. "These are inherently unreliable and untrustworthy judgments that will open the floodgates to the overdiagnosis of mental disorder and promote the missed diagnosis of medical disorder…

Ms Chapman has provided a devastating and compelling critique. It is crucial that DSM 5 tighten its over-inclusive wording to prevent what could otherwise be the wholesale dismissal of real medical symptoms as psychiatric illness- leading to missed diagnoses, incorrect treatment, stigma, and patients understandably feeling greatly misunderstood…
I would suggest reading both Dr. Frances’ and Ms. Chapman’s comments in full. They make a compelling argument. I’ll just add a comment or two in support. These are the shoals of clinical medicine – a place where errors are born, rather than exceptions. In his narrative, Dr. Frances gives an example of his missing a brain tumor. It’s the rare physician who can’t tell that kind of story, sometimes with fatal outcomes. I certainly can. Those cases haunt us forever and teach us to be wary of making a pronouncement like the one suggested. Of course there a number of patients who seem preoccupied with symptoms, but they are hardly a uniform group, and they’re a dangerous group because patients in this category get real illnesses too. So besides the dangers of discounting the patients up-front, there’s the ever present danger of insuring they’ll be discounted later when they really need attention.

I can’t figure out a reason for including this category. First, as I said, it’s not a uniform group. It contains people who are genuinely physically ill but undiagnosed, people seeking some kind of secondary gain, people whose somatic symptoms mask other more dire mental illnesses, prodromal symptoms of psychosis, etc. But further, why lump them together? The only thing I can think of is to label them so as to limit their drain on medical services, a cost-cutting HMO kind of maneuver. It’s certainly hard to imagine that such a diagnosis has an advantage for patients, and diagnosis is, after all, something one does for patients, not to them. Finally, these patients don’t report being mentally ill and rarely seek psychiatric care. I just don’t see the why of it, only the why not. With criteria as loose as those listed, I wouldn’t doubt that this might have a respectable kappa – be reliable. I would rather question it’s validity [or its wisdom].

And as for "First, do no harm." How can such a made-up diagnosis be ever justified? This is one of those places where our diagnosis by symptom list really falls apart. It elevates the old term hypochondria to the level of a Disorder, implying it is a Disease. Danger! Danger!
    December 10, 2012 | 9:47 AM

    As one diagnosed with a medical condition that definitely would have been most likely blown off if god forbid, I was still under psychiatric care, I find this to be one of the most offensive things about psychiatry. Essentially, this is confirming what those of us who have had the misfortune to have a psychiatric label stuck on us know – Once you have one, your credibility ceases to exist. It is very frightening.

    Again, where is the outrage in psychiatry? Why isn’t there a group protesting this? No one seems to give a damm other than you Mickey.

    This is truly disgusting.

    December 10, 2012 | 11:48 AM

    Hi…just noticed you too had commented on this issue…I made comments too on my blog today…wanted to share my concerns here too as I’ve not seen them mentioned elsewhere:

    The Somatic Symptom Disorder category is also of particular concern to those who are suffering from drug iatrogenesis and particularly psychiatric drug withdrawal syndromes. One of the common manifestations of debilitation when struck with withdrawal syndromes are numerous, often bizarre, acute, painful and disabling physical sensations. They include varieties of neuropathies and parasthesias. They are NOT in the patients head. And since the drug use caused these disabling symptoms more drugs to cure them is exactly the wrong way to go. This, of course, already happens. Many people are wrongly diagnosed when they start manifesting adverse reactions or acute withdrawal to drugs. They are often already disbelieved when they start reporting such adverse events.

    There is an ongoing failure to recognize the iatrogenic illness (medically induced physical illness) that these drugs actually cause very often, especially when people withdraw from them but often simply as a result of going on and off them as is routinely done in the treatment of those who are so-called “treatment resistant.” The med “merry-go-rounds” that so many people experience. It’s pretty clear that such treatment is often the cause of the treatment resistance. The body/mind doesn’t like having its nervous system repeatedly jacked around.

    December 10, 2012 | 11:50 AM

    Thank you Mickey, and thank you also to Beyond Meds:


    DSM‘s Somatoform Disorders: millions more might be diagnosed (those with withdrawal syndrome are high risk for such misdiagnosis)

    December 10, 2012 | 3:23 PM

    There are states and conditions similar to “depression” that anyone could conflate with it if they have no idea what else it could be. Anemia can have all the symptoms of “depression” , yet all the body needs is iron, or B-12,

    Fatigue could be misconstrued as “depression” if you don’t know what it is because it is seems more like “depression” than just being tired or exhausted. Fatigue is its own animal, can be profound, and it can occur with no other signs of physical distress so it makes sense for a patient to think that it is “depression”; but a psychiatrist should know better.

    Also, suffering with PTSD can leave you feeling very low; and because it often involves psychological weirdness like forgetting triggers or being completely run over by it with no apparent meta awareness that that is your problem at the moment can easily lead to the conclusion that you must be suffering from “depression.”

    It’s just wrong that psychiatrists and other mental health professionals aren’t required to rule out physical anomalies or drugs before diagnosing and treating someone with psychiatric medication(s).

    December 10, 2012 | 6:26 PM

    Doctors already widely believe adverse effects of drugs and withdrawal symptoms are psychosomatic. This DSM-5 diagnosis won’t change anything, but it is another stupidity of this effort, which has done nothing to increase patient safety or improve clinical practice.

    December 10, 2012 | 10:56 PM

    Let me get this straight…

    The same profession that *knows not* how to search for underlying physical conditions will now place yet another label on its patients…. adding more insult to injury.

    The label belongs on psychiatry.

    Root causes of “mental” illness –



    December 11, 2012 | 6:17 PM

    Cue the robot from “Lost in Space”:

    Danger Will Robinson, Danger! I detect alien presence, and it appears hostile. How ironic Dr Smith seems to resemble those who write this DSM 5 crap!

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