Javier I. Escobar, MD, is Director of the University of Medicine and Dentistry of New Jersey (UMDNJ) – Robert Wood Johnson Medical School (RWJMS) Medically Unexplained Physical Symptoms (MUPS) Research Center, which has been supported with over $4M in funding by the US National Institute of Mental Health (NIMH).
Dr Escobar is a member of the DSM-5 Task Force, serves as Task Force liaison to the Somatic Symptom Disorders Work Group and is said to work closely with this work group.
In the August 2008 Special Report co-authored by Javier Escobar, MD, and Humberto Marin, MD, for Psychiatric Times: Unexplained Physical Symptoms What’s a Psychiatrist to Do?, the authors wrote:
“…Perhaps as a corollary of turf issues, general medicine and medical specialties started carving these syndromes with their own tools. The resulting list of ‘medicalized’, specialty-driven labels that continues to expand includes fibromyalgia, chronic fatigue syndome, multiple chemical sensitivity, and many others.
“…These labels fall under the general category of functional somatic syndromes and seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones. However, using DSM criteria, virtually all these functional syndromes would fall into the somatoform disorders category given their phenomenology, unknown physical causes, absence of reliable markers, and the frequent coexistence of somatic and psychiatric symptoms.”
In Table 1, under the heading “Functional Somatic Syndromes (FSS)” Escobar and Marin list:
Irritable bowel syndrome, Chronic fatigue syndrome, Fibromyalgia, Multiple chemical sensitivity, Nonspecific chest pain, Premenstrual disorder, Non-ulcer dyspepsia, Repetitive strain injury, Tension headache, Temporomandibular joint disorder, Atypical facial pain, Hyperventilation syndrome, Globus syndrome, Sick building syndrome, Chronic pelvic pain, Chronic whiplash syndrome, Chronic Lyme disease, Silicone breast implant effects, Candidiasis hypersensivity, Food allergy, Gulf War syndrome, Mitral valve prolapse, Hypoglycemia, Chronic low back pain, Dizziness, Interstitial cystitis, Tinnitus, Pseudoseizures, Insomnia, Systemic yeast infection, Total allergy syndrome
The Somatic Symptom Disorders Work Group proposes redefining the categories in the Somatoform Disorders section of DSM-IV to legitimize the application of an additional “bolt-on” diagnosis of a ”somatic symptom disorder” for all medical diseases, whether “established general medical conditions or disorders”, like diabetes, cancer or angina, or conditions presenting with “somatic symptoms of unclear etiology”, if the criteria are otherwise met.
These radical proposals for rebranding the Somatoform Disorders categories as Somatic Symptom Disorders and combining a number of existing, little-used categories under a single new term, Somatic Symptom Disorder (SSD), have the potential for bringing many thousands more patients under a mental health banner.
The criteria are highly subjective and difficult to measure.
How will a clinician determine what is “excessive” or“disproportionate” concern? Patients diagnosed with CFS, ME, FM, IBS, CI, CS, chronic Lyme disease and Gulf War illness, or awaiting diagnosis, may be particularly vulnerable to being caught by these criteria because of lack of diagnostic tests and because many psychiatrists and clinicians consider that they are caused by, or maintained by “biopsychosocial” factors and that testing and medical investigations into symptoms should be limited.
Although the Work Group is not proposing to classify CFS and Fibromyalgia, per se, within the Somatic Symptom Disorders, there are considerable concerns that patients with CFS, FM and IBS may be particularly vulnerable to the application of a mental health disorder diagnosis under these CSSD/SSD criteria.
Application of these criteria has the potential for expanding markets for psychiatric services, antidepressants and behavioural therapies like CBT, for the “modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors” for all patients with somatic symptoms, if the clinician considers that the patient’s response (or in the case of a child, a parent’s response) to bodily symptoms and concerns about their health are “excessive”, or the perception of their level of disability “disproportionate”, or their coping styles “maladaptive.
Application of these vague, highly subjective and difficult to measure criteria may have considerable implications for the diagnoses assigned to patients, the provision of social care, the payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out.
The misapplication of a diagnosis of Somatic Symptom Disorder (CSSD), may limit the types of treatment, medical investigations and testing that clinicians are prepared to consider, and which insurers are prepared to fund.
These proposals could potentially result in misdiagnosis with a mental health disorder, misapplication of an additional “bolt-on” diagnosis of a mental health disorder, missed diagnoses through failure to investigate new or worsening symptoms, or in iatrogenic disease from psychotropic drugs.
Families caring for children and young people with any long-term illness may be at increased risk of wrongful accusation of “over-involvement” or “excessive” concern for a child’s symptomatology or of encouraging maintenance of “sick role behaviour” in a sick child or adolescent.
Suzy Chapman’s submission to DSM-5 third draft: Chapman DSM-5 submission 2012