The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill
by Allen Frances
British Medical Journal 2013. 346:f1580The fuzzy boundary between psychiatry and general medicine is about to experience a seismic shift. The next edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [DSM] is scheduled for release this May amid controversy about many of its new disorders. Among these, DSM-5 introduces a poorly tested diagnosis—somatic symptom disorder—which risks mislabeling a sizeable proportion of the population as mentally ill.
The relation between psychiatry and the rest of medicine has been difficult to manage both for mental health practitioners and for primary care doctors, and this is even more problematic for patients caught in-between. The boundary has never been clear cut or static but has shifted back and forth depending on new findings and fashions. The realm of psychiatry would shrink, and that of medicine would expand, whenever advancing science discovered a cause for a previously poorly understood presentation. The classic example of this is “general paresis of the insane,” which went from psychiatry to neurology as soon as the spirochete was identified as the causal agent.
In DSM-5, “somatic symptom disorder” appears in a new section, “Somatic symptoms and related disorders,” which replaces the “Somatoform disorders” section found in DSM-IV. This new category will extend the scope of mental disorder classification by eliminating the requirement that somatic symptoms must be “medically unexplained.” In DSM-5, the focus shifts to “excessive” responses to distressing, chronic, somatic symptoms with associated “dysfunctional thoughts, feelings, or behaviors.” The overinclusiveness of this diagnosis is suggested by the results of the DSM-5 field trial study reported by the somatic symptom disorder work group at the 2012 annual meeting of the American Psychiatric Association. Somatic symptom disorder captured 15% of patients with cancer or heart disease and 26% with irritable bowel syndrome or fibromyalgia, and it had a high false positive rate of 7% among healthy people in the general population. The rate of psychiatric disorder among medically ill patients is unknown, but these rates seem high, and the burden of proof before introducing any new diagnosis is that it has a favourable risk to benefit ratio. Yet the proposed diagnosis is unsupported by any substantial evidence on its likely validity and safety and was strongly opposed by patients, families, caregivers, and advocacy organizations…
The late Thomas Szasz once said: “In the days of the Malleus, if the physician could find no evidence of natural illness, he was expected to find evidence of witchcraft: today, if he cannot diagnose organic illness, he is expected to diagnose mental illness.”9 Szasz’s general critique of psychiatry was too broad, but he was correct when it comes to the loosely defined somatic symptom disorder in DSM-5. Clinicians are best advised to ignore this new category. When a psychiatric diagnosis is needed for someone who is overly worried about medical problems the more benign and accurate diagnosis is adjustment disorder.
Twenty years ago, Dr. Frances chaired the DSM task force, which emphasized “medically unexplained symptoms” as the key feature of somatoform disorders. Where has that got us? Patients feel that their complaints are viewed as inauthentic, and doctors can’t agree about what is or is not medically unexplained. All of this reinforces a mind-body dualism, which is more consonant with the 17th century than the 21st . Psychiatric symptoms and general medical symptoms can and do coexist. We think and feel with our brains and are affected by life experience and the cellular milieu that we live in.
The DSM 5 diagnosis of somatic symptom disorder represents an attempt to correct these problems in DSM IV. The DSM-5 diagnosis does not question the reality of patients’ suffering and emphasizes instead that psychiatric disorders are more properly diagnosed on the basis of features such as disproportionate and excessive thoughts, feelings, and behaviors, rather than by negative features like “medically unexplained symptoms.”
Frances complains that the DSM-5 criteria will be “too loose.” It is worth pointing out that the DSM IV criteria for “Undifferentiated Somatoform Disorder” yielded higher estimates of the population at risk than do the criteria for DSM-5. His final suggestion is that physicians should use a “benign diagnosis.” We agree that the DSM IV diagnoses were highly stigmatizing. We hope that the DSM-5 approach will be less so, particularly with the de-emphasis of medically unexplained symptoms. DSM is hardly “a Bible.” DSM IV wasn’t, and DSM-5 won’t be either. The goal of the DSM is to accurately describe the patient’s presentation with the intention of providing helpful treatment. When a patient is better described by one diagnosis than another, it is sensible to use the one that is more accurate.
The one thing we do agree with Dr. Frances on is the importance of caring for our patients. It is debilitating for individuals suffering from multiple persistent somatic symptoms and distressing preoccupations. The diagnosis of Somatic Symptom Disorder may be a logical next step in recognition and treatment of these patients.
When I look back over my career and the mistakes made along the way, the biggest errors were categorical errors – by which I mean mistaking mental problems for physical disease and vice versa – and I’m sorry to say that several were fatal. They weren’t mistakes of indifference, they were just plain the result of being wrong. I doubt there are many physicians who have escaped such errors in a long career. It’s the kind of thing doctors rarely talk about except with old doctor friends, and it often evokes similar stories in the process. These are the cases that haunt us, and the ones that made us better doctors.
One thing I learned along the way is that a diagnosis of mental disorder should never be a default diagnosis – a diagnosis made because you can’t find a physical cause for symptoms. Granted, somatic symptoms are a frequent concomitant of psychiatric disorder, but to my mind, if you can’t make a diagnosis of a specific psychiatric disorder, it’s still an open question awaiting further developments. This is one of the places where the descriptive model of psychiatric diagnosis falls in a black hole – and it’s a dangerous black hole. Sure there are people who have somatic symptoms that can’t be explained on the basis of physical illness – all kinds of people. But to call that a psychiatric disorder is playing with fire and gives the referring physician and the psychiatrist some kind of false comfort in having a pigeon hole to put the patient into. But that comfort replaces a vigilance that needs to stay in place.
A psychiatric diagnosis of Somatic Symptom Disorder justifies prescribing psychiatric drugs. Doctors throw these prescriptions at people, mostly women, who complain of symptoms the clinician can’t diagnose or doesn’t want to spend the time to diagnose.
It’s called Somatic Symptom Disorder because Shut Up and Stop Complaining would be just too rude.
But what constitutes a “psychiatric explanation?” I am thinking conversion disorder here. Anyone who has seen cases of non-epileptic seizures and unexplained sensory-motor (blindness, limb paralysis) phenomena and has had the benefit of psychodynamic training can, with the use of tools like psychological and “projective” tests, uncover a plausible, and often compelling, psychological explanation for the symptoms. Is DSM-5 throwing all of that out?
Dr Frances wants to use the Adjustment Disorder waste basket – isn’t that also a psychiatric label that leads to medical/psychiatric treatment? Who decides what is excessive?
“If one does not cast a large net, one cannot catch many fish.”
Could the vision for the DSM-V been based upon a chinese buffet attended by APA leadership – and the fortune cookie that was cracked open following lunch?
Enquiring minds want to know…
Duane
“Be careful what you ask for – you might just get it.”
Fortune cookie from more recent buffet….
Soon to be on display at the ‘Death of Psychiatry’ exhibit.
Duane
Gotta love fortune cookies.
Much better than science….
Duane
Regarding the “medically unexplained”:
I found already the “medically unexplained” criteria problematic – and retaining it does not make things better any more than dropping it.
First, it places those practitioners using such diagnoses firmly outside the field of medical sciences. Does that mean that psychiatry is not bound by the usual rules regarding medicine? Can they do first some harm? And whereas any “medically explained” health problem needs evidence (you can’t just claim that a patient is suffering from a pathogen, you either need direct evidence or clear symptoms), any “medically unexplained” “disorder” on the other hand can simply be postulated.
Secondly the whole “medically unexplained” criteria makes it clear what a disaster this “somatic” business is: People’s health problems are treated without knowing what they actually have. Now that in itself would be fine (doctors *have* to treat patients and can not wait until it is fully known what they have), if not it was postulated that it *is* a psychiatric problem, and (pharmaceutically) treated as such. And by what measure is it “medically unexplained”? If the DSM would be honest, it would call it “currently medically unexplained” – but then the whole business would be in question, now wouldn’t it? Everybody would see that they do *not* have a clue what they are treating.
PS: Having personally traced most of my health problem – which included Anxiety and Depression – to nutritional causes, I am doubtful that the professionals – both of the medical and non-medical variety – are in a position to make so much as a dent in the diseases they try to treat. I will not bore you much with the gory nutritional details (I am confident others will do that in the coming years) so I will just say this: Anybody trying to find out the causes of health problems *will* have to look at what has changed with regards to nutrition compared to our environment of evolutionary adaptation. And at the risk of sounding like a crank I will name just two (of the most recent) nutritional additions that in view are prime candidates as causative agents of disease: Seed oil and pasteurized milk. Ignore evolution at your own risk and at the risk of the health of your patients.
…”actively dangerous” … “implies something we cannot know” … till good doctors go outside reductionistic scripts and accompany us to health in body/mind nutrition, vast, more than food, balanced endocrinology, environmental issues, people, violence, war, poverty, …
“I do not know” signals humility, shared humanity, opens new vistas, words spoken by wise persons. What’s the difference between God and a psychiatrist? – God knows she’s not a psychiatrist. The profession of psychiatry is destructively selfdestructing.
@ Tom
“Conversion Disorder” will remain a discrete category within DSM-5.
The following categories will sit under the new “Somatic Symptom and Related Disorders” section that will replace DSM-IV’s “Somatoform Disorders” section:
Source: DSM-5 Table of Contents: Page 3:
http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/DSM-5-TOC.pdf
Somatic Symptom and Related Disorders
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder (Functional Neurological Symptom Disorder)
Psychological Factors Affecting Other Medical Conditions
Factitious Disorder
Other Specified Somatic Symptom and Related Disorder
Unspecified Somatic Symptom and Related Disorder
The new category ‘Somatic Symptom Disorder’ collapses and replaces five DSM-IV Somatoform Disorders within a single new category. SSD will replace:
somatization disorder [300.81]
hypochondriasis [300.7]*
undifferentiated somatoform disorder [300.82]
pain disorders
somatoform disorder NOS
All seven disorders have discrete definitions and criteria sets.
To meet the criteria for the new category, SSD, (Note as the draft criteria stood in June 2012) the following need to be fulfilled:
One or more somatic (bodily) symptoms that are distressing and/or result in significant disruption in daily life.
Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns:
At least one of the following needs to be met:
A Disproportionate and persistent thoughts about the seriousness of symptoms;
B Persistently high level of anxiety about health or symptoms;
C Excessive time and energy devoted to these symptoms or health concerns;
Chronicity: typically longer than 6 months.
There are three optional severity specifiers: Mild SSD; Moderate SSD and Severe SSD; and a “Predominately Pain” specifier that replaces the DSM-IV Pain disorders.
One of the DSM-IV Pain disorders (Pain Disorder associated with a general medical condition for which “Psychological factors, if present, are judged to play no more than a minimal role”) was not considered a mental disorder for DSM-IV and was coded on Axis III with general medical conditions.
For DSM-5, all Pain disorders are now absorbed into the new category “SSD”.
In DSM-IV, Psychological Factors Affecting Medical Condition was not coded as a mental disorder but located under the DSM-IV “V code” section. For DSM-5, PFAMC is relocated under the new category “SSD”.
*Hypochrondiasis: For DSM-5, hypochondriais with somatic symptoms is being absorbed into “Somatic Symptom Disorder.” Hypochondriasis without somatic symptoms is being replaced with “Illness Anxiety Disorder.”
For DSM-5’s “SSD”, there is no longer the requirement for somatic symptoms to be “medically unexplained”.
Instead, the focus shifts to the individual’s psychological and bevavioural response to distressing, persistent, bodily symptoms and the extent to which the clinician considers the person’s responses to be “disproportionate” or “excessive” or “maladaptive.”
“…[The SSD Work Group’s] framework will allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome…” [2]
“…These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis. Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met…” [3]
For testing reliability of (what was then known as CSSD), three groups were studied for the field trials:
488 healthy patients; a “diagnosed illness” group of 205 patients with cancer and malignancy (some in this group were said to have severe coronary disease) and a “functional somatic” group comprising 94 people with “irritable bowel” or “chronic widespread pain” (a term used synonymously with fibromyalgia).
Patients in the study were required to meet one to three cognitions: Do you often worry about the possibility that you have a serious illness? Do you have the feeling that people are not taking your illness seriously enough? Is it hard for you to forget about yourself and think about all sorts of other things?
Dr Joel Dimsdale reported that if the response was “Yes – a lot.” then [CSSD] was coded for.
15% of the cancer and malignancy group met SSD criteria when “one of the B type criteria” was required; if the threshold was increased to “two B type criteria” about 10% met criteria for dual-diagnosis of diagnosed illness + Somatic Symptom Disorder.
For the 94 irritable bowel and “chronic widespread pain” study group, about 26% were coded when one cognition was required; 13% coded with two cognitions required.
7% of the “healthy” control group met the criteria for a dx of SSD.
So it’s important to note that for DSM-5, SSD can be applied to all of the following patient groups:
Chronic diagnosed illness (cancer, long-term pain disorders, heart disease, angina, diabetes, MS, Lupus etc);
The so-called “functional somatic syndromes” – CFS, IBS, FM and others;
Patients with somatic symptoms for which no etiology has yet been determined;
Patients with psychiatric disorders.
I’ll link to some recent APA documents on SSD in the next comment and also to David Kupfer’s rebuttal on Huff Po.
2 Dimsdale J, Creed F. DSM-V Workgroup on Somatic Symptom Disorders: the proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report. J Psychosom Res 2009;66:473–6.
3 DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions and Justification of Criteria-Somatic Symptoms documents, published May 4, 2011 for the second DSM-5 stakeholder review.
David J. Kupfer, M.D, Chair, DSM-5 Task Force on Huff Po:
Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care, February 8, 2013:
http://www.huffingtonpost.com/david-j-kupfer-md/dsm-5_b_2648990.html
Article: Somatic Chapter Drops Centrality Of Unexplained Medical Symptoms, Psychiatric News, March 1, 2013, Mark Moran:
http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1659603
APA Somatic Symptom Disorder Fact Sheet:
http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/DSM-5-Somatic-Symptom-Disorder.pdf
Extracts from the DSM-5 Somatic Symptom Disorders Work Group “Disorder Descriptions” PDF document, published May 4, 2011 for the second DSM-5 stakeholder review:
“…The presentation of these symptoms may vary across the lifespan. A corroborative historian with a life course perspective may provide important information for both the elderly and for children…”
“…In the elderly somatic symptoms and comorbid medical illnesses are more common, and thus a focus on criteria B becomes more important. In the young child, the “B criteria” may be principally expressed by the parent…”
It appears from this document that the “B type” criteria are intended to be applied to parents perceived as having “excessive thoughts, feelings, and behaviors,” or “disproportionate and persistent concerns” relating to somatic symptoms or associated health concerns, or considered to be spending “excessive time and energy devoted to [their child’s] symptoms or health concerns.”
There is no evidence that SSD has been tested by the APA or by any other research group for its safety of application in children and young people – an issue that virtually no professional has publicly commented on. Why has this section of DSM-5 seemingly been so overlooked by medical professionals both in and outside psychiatry and psychosomatics?