Global creep of DSM-5′s Somatic symptom disorder

Post #303 Shortlink: http://wp.me/pKrrB-3Qq

Update at April 14, 2014:

Written response (April 10, 2014) from Independent Hospital Pricing Authority (IHPA) to request for clarification regarding the term ‘Somatic symptom disorder’ and Australia’s clinical modification of ICD-10, ICD-10-AM:

PDF: IHPA response re SSD and ICD-10-AM


 

As previously posted:

In the previous posting Update on proposal to add DSM-5′s Somatic symptom disorder to ICD-10-CM I reported that NCHS is preparing to rubber stamp proposals to insert Somatic symptom disorder into the U.S.’s forthcoming clinical modification of ICD-10.

Comments/objections to Diagnosis Agenda proposals submitted at the March meeting need to be sent by email to NCHS at nchsicd9CM@cdc.gov by June 20th.

1] According to this Australian legislative document:

http://www.comlaw.gov.au/Details/F2014L00304

Australian Government, Statement of Principles concerning somatic symptom disorder No. 24 of 2014

for the purposes of the Veterans’ Entitlements Act 1986 and Military Rehabilitation and Compensation Act 2004

“Somatic symptom disorder attracts ICD-10-AM code F45.1.”

For the purposes of the Statement of Principles:

“ICD-10-AM code” means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Eighth Edition, effective date of 1 July 2013, copyrighted by the Independent Hospital Pricing Authority, and having ISBN 978-1-74128-213-9;”

The Australian ICD-10-CM, Eighth Edition, July 2013 is not in the public domain. As I do not have access to a copy, I have contacted the relevant body for clarifications.

I have asked whether Somatic symptom disorder has been added to the Eighth Edition of ICD-10-AM as an Inclusion term to F45.1 Undifferentiated somatoform disorder in the Tabular List and Alphabetical Index.

Or, whether this legislative document relies on the ICD cross-walk codes as published in the DSM-5 in May 2013 for the cross-walk between DSM-5 disorders and the disorders in the U.S.’s ICD-9-CM and forthcoming ICD-10-CM.

Or, whether the legislative document relies on a cross-walk between DSM-5 disorders and ICD-10-AM codes developed specifically in relation to the ICD-10-AM Eighth Edition, July 2013.

I will update this post when I have received clarification.

According to this page: http://nccc.uow.edu.au/icd10am-achi-acs/overview/icd10am/index.html

“[Australia's] ICD-10-AM has also enjoyed more widespread use, having been assessed, found suitable and adopted by many other countries, including: New Zealand, Ireland, Singapore, Slovenia.”

I am unable to confirm how many countries that have adopted ICD-10-AM have migrated from earlier editions to the July 2013 edition or are preparing to migrate to the most recent edition.

Other clinical modifications (CMs) of ICD-10:

Canada (ICD-10-CA): The most recent edition of ICD-10-CA is the 2009 edition Volume One: Tabular List 2009. Canada is anticipated to adopt a CM of ICD-11 before the U.S. does, but in meantime, an updated edition of ICD-10-CA might be anticipated, especially given the recent extension to the ICD-11 development timeline. Canadians will need to be alert to the potential for addition of SSD as an inclusion term to the next edition of ICD-10-CA.

Germany (ICD-10-GM): There is an ICD-10-GM version for 2014. There is no SSD under F45.x or under any other code, but watch for any updated versions released prior to transition to a CM of ICD-11.

Thailand (ICD-10-TM): There does not appear to be a more recent version of the Thai clinical modification than the online version for 2007, but watch for SSD in any updated versions prior to potential transition to a CM of ICD-11. ICD-10-TM Online version for 2007.

ICD-11 Beta drafting platform:

There is no documentary evidence of a proposal to add SSD, per se, to ICD-11. However, the wording for the Definition for Bodily distress disorder, as it currently stands in the Beta drafting platform, is drawn from the Gureje, Creed 2012 paper on the S3DWG sub working group’s emerging proposals for ICD-11 [1].

The paper described a simplified disorder framework – a construct into which DSM-5′s Somatic Symptom Disorder could be comfortably integrated, thus facilitating harmonization between the respective ICD-11 and DSM-5 disorder construct and criteria replacements for the Somatoform disorders classifications.

As with DSM-5′s SSD, for the emerging proposals for BDD, the focus was not on symptoms counts, or on strict symptom patterns or clusters from one or more body systems, or on whether symptoms were determined as being “medically explained” or “medically unexplained,” but on the perception of disproportionate or maladaptive psychobehavioural responses to, or excessive preoccupation with any troublesome chronic bodily symptom(s). And that in doing away with the “unreliable assumption of its causality” the diagnosis of BDD would not exclude the presence of a co-occurring physical health condition – which is very close to SSD’s defining characteristics.

1. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Abstract. Full text behind paywall]

2] On the Patient.co.uk site, a peer reviewed article on Somatic symptom disorder:

http://www.patient.co.uk/doctor/somatic-symptom-disorder

This article is not a recommendation and it draws heavily on the DSM-IV and current ICD-10 Somatoform disorders framework, criteria and literature. Though it does highlight that DSM-5 has a new, simplified framework and reformulated criteria that rely less on strict patterns of somatic symptoms and more on the degree to which a patient’s thoughts, feelings and behaviours about their symptoms are considered disproportionate or excessive; that for DSM-5, “medically unexplained” is de-emphasized – symptoms may or may not be associated with another medical condition and patients with organic comorbidities such as heart disease, osteoarthritis or cancer, who would have previously been excluded under DSM-IV, can now be included in the diagnosis of SSD.

There is little published research examining the reliability, utility, epidemiology, clinical characteristics or treatment of Somatic symptom disorder as a diagnostic construct and none of the article’s references are for papers specifically using the new Somatic symptom disorder criteria.

3] Somatic symptom disorder in a BMJ Rapid Response:

Rapid Response to: Clinical Review, Fibromyalgia by Anisur Rahman, Martin Underwood, Dawn Carnes [Full text for Clinical Review behind paywall]

http://www.bmj.com/content/348/bmj.g1224/rr/689294

Rapid Response: Fibromyalgia: an unhelpful diagnosis for both patients and doctors [Full text for Rapid Response accessible]

Christopher Bass, consultant in liaison psychiatry, John Radcliffe Hospital , Oxford OX3 9DU

Dr Max Henderson, senior lecturer in Epidemiology and Occupational psychiatry, Inststitute of psychiatry, Kings College London 

According to the authors, fibromyalgia ( coded in ICD-10 under Chapter XXIII Diseases of the musculoskeletal system and connective tissue, at M79.7 ) is more appropriately described in terms of “polysymptomatic distress”; “polysymptomatic distress has been recognised as a somatoform disorder, specifically as a somatic symptom disorder or SSD,” and that since “FM overlaps with other disorders with medically unexplained symptoms such as irritable bowel syndrome and chronic fatigue syndrome” it is more appropriate to treat them with multidisciplinary teams within the same specialised service in the general hospital.

4] This commentary by infectious disease specialist, Judy Stone, MD, at Scientific American blogs, mentions concerns around SSD:

Have Pain? Are You Crazy? Rare Diseases Pt. 2

By Judy Stone | February 18, 2014

“It’s all in your head,” patients with unexplained pain or unexpected symptoms often hear…

5] Halifax Somatic Symptoms Disorder Trial

http://clinicaltrials.gov/show/NCT02076867

ClinicalTrials.gov Identifier: NCT02076867

Sponsor: Capital District Health Authority, Canada

The purpose of this study is to compare the effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP) plus Medical Care As Usual (MCAU) compared to MCAU for Somatic Symptom and Related Disorders (SSRD). Consenting patients presenting to the emergency department with suspected SSRD will be randomly allocated to receive either 8 weekly individual sessions of ISTDP or to an 8-week wait list followed by ISTDP. MCAU including emergency department and/or family doctor consultation is available throughout trial participation. The primary outcome measure is participant self-reported somatic symptoms at week 8.

 

Update on proposal to add DSM-5′s Somatic symptom disorder to ICD-10-CM

Post #302 Shortlink: http://wp.me/pKrrB-3PE

Update at April 5, 2014: Implementation of the U.S.’s forthcoming adaptation of ICD-10, ICD-10-CM, has been kicked further down the road to October 1, 2015. Bill H.R. 4302, known as the PAM Act (Protecting Access to Medicare Act) was signed by President Obama on April 1, 2014. This means that the U.S. won’t now transition from ICD-9-CM to ICD-10-CM for another year. CMS has yet to issue a statement or update its webpages.

Update at April 5, 2014: The Summary of the March 19–20, 2014 meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee meeting has now been posted

Lots of “outrage” over SSD and DSM-5 but I see little evidence of sustained “outrage” over proposals to add SSD as an Inclusion term to the U.S.’s ICD-10-CM.

If NCHS rubber stamps the addition of Somatic Symptom Disorder to ICD-10-CM it could leverage the future replacement of the existing Somatoform disorders categories with this new, poorly validated single SSD diagnostic construct, bringing ICD-10-CM in line with DSM-5.

There are implications for ICD-11, too.

Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. adaptation of ICD-10 may make it easier for ICD-11 Revision Steering Group to justify proposals to replace the existing ICD-10 Somatoform disorders categories with a single, new ICD construct contrived to incorporate SSD-like characteristics and facilitate harmonization between ICD-11 and DSM-5 disorder terms and diagnostic criteria.

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This post updates on proposals at the March meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee to add DSM-5′s controversial new Somatic symptom disorder to ICD-10-CM.

But first, a necessary recap of the September meeting:

ICD-10-CM/PCS Coordination and Maintenance Committee meetings provide a public forum to discuss proposed changes to the U.S.’s forthcoming ICD-10-CM and ICD-10-PCS, scheduled for implementation on October 1, 2014.

The meetings, which are co-chaired by representatives for CMS and NCHS, take place, in public, in March and September, followed by public comment periods.

The fall meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee was held on September 18–19, 2013.

On Day Two of the September meeting, American Psychiatric Association’s Darrel Regier, MD, had proposed six new DSM-5 disorders for inclusion in ICD-10-CM.

On Page 45 and 46 of the Diagnosis Agenda, under Additional Tabular List Inclusion Terms for ICD-10-CM, a number of other changes to specific Chapter 5 F codes had also been proposed. These were introduced en masse, by CDC’s Donna Picket. (Reached on Day Two, at 1:22:21 in from the start of Videocast Four.)

This section of the Diagnosis Agenda included the proposals to add the new DSM-5 disorders: Somatic symptom disorder (proposed to Add as Inclusion term to F45.1 Undifferentiated somatoform disorder) and Illness anxiety disorder (proposed to Add as Inclusion term to F45.21 Hypochondriasis) to ICD-10-CM’s Chapter 5 codes.

(F45.1 and F45.21 are the ICD-10-CM codes to which these two new APA disorders are already cross-walked in the DSM-5.)

ICD10CM 4

Source: Page 45, Diagnosis Agenda (Topic Packet), September 18–19, 2013 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting

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Videocasts of the entire September 2013 meeting proceedings, Diagnosis Agenda (Topic Packet), Procedural Agenda, Meeting materials etc can be found in Dx Revision Watch Post #277.

Note: there was no proposal at the September 2013 meeting to create a unique code for either Somatic symptom disorder (SSD) or Illness anxiety disorder, for either 2014 or October 1, 2015 implementation, and no proposal that Somatic symptom disorder should replace or subsume any of the existing ICD-10-CM F45.x Somatoform disorders. Note also, these proposals are specific to the forthcoming U.S. clinical modification of ICD-10.

In relation to the section of the Agenda on Pages 45 and 46, CDC’s, Donna Picket, had stated:

1:22:21 in: Diagnosis Agenda: “Additional Tabular List Inclusion Terms for ICD-10-CM”
Donna Pickett (CDC): “…And just to complete the package, there are other Tabular List proposals that appear on Page 45 and 46 that we would also invite your comments on. And again, with some of the terminology changes that Dr Regier has described the intent here is to make sure that if those terms are being used, that they do have a home somewhere within ICD-10-CM to facilitate people looking these up. So we invite comments. We’re showing the Tabular List proposed changes; however, there obviously would be associated Alphabetic Index changes with that which we didn’t show just to keep the package a little bit smaller…”
Source: [Unofficial transcription from Video Four, September 2013 ICD-9-CM C & M Committee meeting.]

There were no questions or comments from the floor or by phone link on any of the proposals listed on Pages 45 and 46 under “Additional Tabular List Inclusion Terms for ICD-10-CM” and no discussion or queries on any of the individual proposals listed under under this section of the Agenda between the meeting co-chairs and APA’s, Dr Regier.

NCHS’s decision on proposals to add Somatic symptom disorder (SSD) and Illness anxiety disorder as Inclusion terms to ICD-10-CM Tabular List Chapter 5, and to also add to the Index, isn’t known and may not be evident until the next ICD-10-CM Addenda is released, later this year, or the Final Addenda released.

Some of the objections submitted to the proposal to add Somatic symptom disorder (SSD) as an Inclusion term in ICD-10-CM are collated on Dx Revision Watch here.

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March meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee

This meeting took place on March 19–20, 2014. I was unable to attend as I live in the UK.

The ICD-9-CM and ICD-10-CM Timeline and Diagnosis and Procedure Codes Agenda (Topic Packet) can be found here, on the CDC website:

Proposals (Topic Packet) March 19-20, 2014

Procedure Agenda, Meeting Materials and Handouts can be downloaded from Zip files here, on the CMS website:

Meeting Materials March 19-20, 2014

A Summary Report of the Diagnosis part of the meeting is scheduled to be posted on the NCHS website, in June.

A Summary Report of the Procedure part of the meeting is scheduled to be posted on the CMS website, in June.

April 17, 2014: Deadline for receipt of public comments on proposed procedure code revisions discussed at the March 19, 2014 ICD-10 Coordination and Maintenance Committee meeting for implementation on October 1, 2014.

June 20, 2014: Deadline for receipt of public comments on proposed code revisions discussed at the March 19–20 meeting for implementation on October 1, 2015.

ICD-10-CM is currently subject to a partial code freeze. During the freeze, the public will be asked to comment on whether or not a proposal should be approved, and if not, why; and whether requests for new diagnosis or procedure codes should be created based on the criteria of the need to capture a new technology or disease. Any code requests that do not meet the criteria will be evaluated for implementation within ICD-10-CM on and after October 1, 2015 once the partial freeze has ended.

Comments on the diagnosis proposals presented at the ICD Coordination and Maintenance Committee meeting should be sent, preferably by email, to the following address by June 20th deadline: nchsicd9CM@cdc.gov

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The Two Day proceedings were streamed live and can be watched on YouTube:

Video One: Day One: Morning Session: Procedural Codes: 2014 Mar 19th, FY 2014 ICD-10 Coordination and Maintenance Committee

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Video Two: Day One: Afternoon Session: Procedural Codes: 2014 Mar 19th, FY 2014 ICD-10 Coordination and Maintenance Committee

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Video Three: Day Two: Diagnosis Codes: 2014 Mar 20th, FY 2014 ICD-10 Coordination and Maintenance Committee

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Page 64, Topic Packet: http://www.cdc.gov/nchs/data/icd/Topic_packet_3_19_2014.pdf

[Extract]

Chapter 5 Addenda

The American Psychiatric Association (APA) proposes the following addenda changes to the ICD-10-CM Tabular and Index, specifically to Chapter 5, Mental, Behavioral and Neurodevelopmental disorders (F01-F99).

The APA indicates that these revisions are necessary because DSM-5 contains several new diagnoses, as well as new disorder titles, that do not map well to any existing ICD-10-CM codes.

Because of this, they are proposing numerous new index entries and tabular inclusion terms to ensure that coders can correctly identify the codes to use. The APA proposes that these changes will also ensure that new DSM-5 disorder titles correspond to a valid ICD-10-CM code.

Many of the changes in the proposed addenda relate to the reconceptualization of the substance use disorders from having separate disorder names and codes for substance abuse and dependence. However, extensive scientific evidence was assembled to show that, rather than existing as two separate disorders, these conditions exist on a spectrum that the APA has now conceptualized as ranging from mild to moderate to severe. In order to make the closest approximations with existing ICD-10-CM codes, it is noted that codes for mild substance use disorders correspond to the abuse codes and codes for moderate and severe substance use disorders correspond to dependence codes. The APA may recommend changes in the structure and names of ICD-10-CM substance related disorders, in the future, however at the present time they are only recommending the addition of the new terminology as inclusion terms.

The following addenda are proposed for implementation on October 1, 2015

[...]

1:12:12 in from start of YouTube Three: Chapter 5 Addenda Proposed Tabular Modifications.

1:12:12 Beth Fisher (CMS): Introduces proposals for [Tabular] modifications from APA for Chapter 5. These are all Addenda type changes because [ICD-10-CM is] in code freeze mode, we didn’t have the opportunity to do new codes just yet. Hands podium to Darrel Regier, MD.

1:13:01 Darrel Regier (APA): Mapping DSM-5 to ICD-10-CM codes; Major change to rename Dementias group to Major Neurocognitive Disorders, because including in this group some neurocognitive deficit conditions such as Traumatic brain injury and other neurocognitive disorders that are not inherently some of the neurodegenerative diseases, such as Alzheimer’s, Picks Disease. (Page 64 Diagnosis Agenda)

1:14:02 Darrel Regier (APA): We’ve also introduced [in DSM-5] a Mild neurocognitive disorder that reflects the Mild cognitive impairment, MCI, that is currently in ICD-9, ICD-10…

1:15:06 Darrel Regier (APA): A lot of significant changes to substance abuse disorder area which will require some notes and guidelines…

1:15:27 Darrel Regier (APA): [APA has] a number of new disorders…15 new disorders that are in the DSM-5, but there were 50 disorders that were actually subsumed into a spectrum of conditions that dropped the total number of disorders by something like 28; so you had 50 disorders that collapsed into 22 disorders. Among those, some of the most prominent – Aspergers, Autism, Pervasive developmental disorder NOS, into a single Autism spectrum disorder…assessed on two domains…assessed in terms of level of severity instead of categorical distinctions…

1:17:04 Darrel Regier (APA): Eliminating distinction between abuse and dependence so that on a continuum of Mild, Moderate, Severe…no strict separation between abuse category and dependence…

1:21:00: Question from floor re Alcohol abuse, Alcohol dependence.

1:31:15 Beth Fisher (CDC): Some of these Inclusion terms may have been proposed at September 2013 meeting. (But does not explain the reason for their being resubmitted at the March meeting.)

1:31:34 Beth Fisher (CDC): Begins running through all Addenda Additions.

1:31:42 Beth Fisher (CDC): At F44 Dissociative and conversion disorders, Add Conversion disorder, in parenthesis, functional neurological symptom disorder as Inclusion term.

March 2014 C and M meeting Conversion disorder (FNSD)

Source: ICD-10-CM C & M Committee meeting, March 20, 2014, Screenshot Video Three

Note, there was no proposal under these Proposed Tabular Modifications to Add Somatic symptom disorder as Inclusion term to F45.1 Undifferentiated somatoform disorder to the Tabular List. But the proposal to Add Somatic symptom disorder as an Inclusion term to F45.1 Undifferentiated somatoform disorder to the Tabular List and to the Alphabetical Index had been proposed at the September 2013 meeting.

Also, no proposal to Add Illness anxiety disorder to the Tabular List, but again, this had been proposed at the September 2013 meeting (under F45.21), for both the Tabular List and the Index. (Decisions on all four of these September 2013 meeting proposals are unknown.)

1:34:06 Beth Fisher (CMS): Concludes proposed Addenda Additions to Chapter 5 Tabular List.

1:34:12 Beth Fisher (CMS) Moves onto Proposed Index Modifications from Page 82, Topic Packet.

1:42:36 Beth Fisher (CMS) Page 89: [Under main Index term "Disorder"] And then Somatic symptom disorder to F45.1.

Page 89, Diagnosis Agenda Add Somatic symptom disorder

March14 ICD-10-CM Cand M SSD to Index

Source: ICD-10-CM C & M Committee meeting, March 20, 2014, Screenshot Video Three

(No comments from floor regarding proposal to Add SSD to Index, or queries in respect of outcome of September meeting proposals. It was not feasible for me to participate in this meeting via phone link from UK to query.)

Note, there was no proposal under Proposed Index Modifications to add Illness anxiety disorder to the Index, but this proposal had been included in the September 2013 Topic Packet. Why SSD has been resubmitted for consideration for addition ro the Index at the March 2014 meeting is unclear, and as I say, the outcome of proposals for the September meeting for both SSD and IAD to be added to both Tabular List and to Index is unknown.

1:44:25 Beth Fisher (CMS): Concludes proposed Addenda Additions to Chapter 5 Alphabetical Index. Invites comments.

1:44:26: Questions from floor regarding Alcohol; Cannabis; Cocaine use; Implications for legal differences between states for use of cannabis. Question regarding Neurodegeneration due to alcohol.

1:50.02 Beth Fisher (CMS): Other Addenda (Ed: presumably Tab and Index Addenda on pp 91–93 and 93–97) were reached on Day One, as there was time, so not being presenting on Day Two. Invites further comments.

1:50.27 Donna Picket (CDC): Adjourns meeting. Reminds floor (and participants via phone link/videocasts and non attendees), to submit comments on Diagnosis proposals by June 20 deadline.

1:51:07 Question from floor: Process question: if these proposals are all approved, when will they be approved and when will they be effective, because we want to notify our members of what codes to use?

1:51:32: Donna Pickett (CDC): All of these being presented were for consideration for implementation in October 1, 2015. Within 2015, we have a huge body of work that has been accumulating during partial code freeze and we’ve encouraged comments to come in about the timing for making the Final Addenda available. The typical time frame we have used in the past is posting [Addenda] in June and proposals to become effective October 1, of that same year. However, issues have arisen because there is a huge body of work and it was mentioned, yesterday, [during Meeting Day One] that the industry may want to have an Addenda released earlier and we invited comment on that, because of the amount of work that would need to go into incorporating the changes into the relevant systems and programs etc. If we were to stay with the traditional process, the Addenda would be made available in June. Meeting concluded.

Comments on the diagnosis proposals presented at the ICD-10-CM Coordination and Maintenance Committee meeting should be sent, preferably by email, to the following address by June 20th deadline: nchsicd9CM@cdc.gov

Clarification: Coalition for Diagnostic Rights

A website called Coalition for Diagnostic Rights has recently been launched.
The site includes references to Suzy Chapman and to Dx Revision Watch.
Suzy Chapman/Dx Revision Watch is not associated with or affiliated to the Coalition for Diagnostic Rights website or with any organization associated with that site, and has no responsibility for content published on that site, or published in the name of that site on other platforms.
Suzy Chapman
Dx Revision Watch

New paper by Wolfe et al on reliability and validity of SSD diagnosis in patients with Rheumatoid Arthritis and Fibromyalgia

Post #295 Shortlink: http://wp.me/pKrrB-3LP

This post is an update to Post #284, November 17, 2013, titled:

Correspondence In Press in response to Dimsdale et al paper: Somatic Symptom Disorder: An important change in DSM

In December 2013, Journal of Psychosomatic Research published four letters in response to the Dimsdale el al paper including concerns from Winfried Häuser and Frederick Wolfe for the reliability and validity of DSM-5′s new Somatic symptom disorder:  The somatic symptom disorder in DSM 5 risks mislabelling people with major medical diseases as mentally ill.

A new paper has been published by PLOS One on February 14, 2014:

Symptoms, the Nature of Fibromyalgia, and Diagnostic and Statistical Manual 5 (DSM-5) Defined Mental Illness in Patients with Rheumatoid Arthritis and Fibromyalgia Frederick Wolfe, Brian T. Walitt, Robert S. Katz, Winfried Häuser

The paper is published under Open Access and includes the full SSD criteria in Table S1

The paper’s references include the following commentaries and an article by science writer, Michael Gross:

Frances A, Chapman S (2013) DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. Australian and New Zealand Journal of Psychiatry 47: 483–484. doi: 10.1177/0004867413484525 [PMID 23653063]

Frances A (2013) The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ: British Medical Journal 346. doi: 10.1136/bmj.f1580 [PMID 23511949]

Gross M (2013) Has the manual gone mental? Current biology 23: R295–R298. doi: 10.1016/j.cub.2013.04.009 Full text

Full paper, Tables and Figures in text or PDF format:

Symptoms, the Nature of Fibromyalgia, and Diagnostic and Statistical Manual 5 (DSM-5) Defined Mental Illness in Patients with Rheumatoid Arthritis and Fibromyalgia Frederick Wolfe, Brian T. Walitt, Robert S. Katz, Winfried Häuser

Text version

PDF version

Abstract

Purpose

To describe and evaluate somatic symptoms in patients with rheumatoid arthritis (RA) and fibromyalgia, determine the relation between somatization syndromes and fibromyalgia, and evaluate symptom data in light of the Diagnostic and Statistical Manual-5 (DSM-5) criteria for somatic symptom disorder.

Methods

We administered the Patient Health Questionnaire-15 (PHQ-15), a measure of somatic symptom severity to 6,233 persons with fibromyalgia, RA, and osteoarthritis. PHQ-15 scores of 5, 10, and 15 represent low, medium, and high somatic symptom severity cut-points. A likely somatization syndrome was diagnosed when PHQ-15 score was ≥10. The intensity of fibromyalgia diagnostic symptoms was measured by the polysymptomatic distress (PSD) scale.

Results

26.4% of RA patients and 88.9% with fibromyalgia had PHQ-15 scores ≥10 compared with 9.3% in the general population. With each step-wise increase in PHQ-15 category, more abnormal mental and physical health status scores were observed. RA patients satisfying fibromyalgia criteria increased from 1.2% in the PHQ-15 low category to 88.9% in the high category. The sensitivity and specificity of PHQ-15≥10 for fibromyalgia diagnosis was 80.9% and 80.0% (correctly classified = 80.3%) compared with 84.3% and 93.7% (correctly classified = 91.7%) for the PSD scale. 51.4% of fibromyalgia patients and 14.8% with RA had fatigue, sleep or cognitive problems that were severe, continuous, and life-disturbing; and almost all fibromyalgia patients had severe impairments of function and quality of life.

Conclusions

All patients with fibromyalgia will satisfy the DSM-5 “A” criterion for distressing somatic symptoms, and most would seem to satisfy DSM-5 “B” criterion because symptom impact is life-disturbing or associated with substantial impairment of function and quality of life. But the “B” designation requires special knowledge that symptoms are “disproportionate” or “excessive,” something that is uncertain and controversial. The reliability and validity of DSM-5 criteria in this population is likely to be low.

 

Reminder: Next meeting of ICD-10-CM/PCS Coordination and Maintenance Committee: March 19-20, 2014

Post #290 Shortlink: http://wp.me/pKrrB-3F1

Update at February 15, 2014:

Tentative diagnosis agenda posted for March 19–20, 2014 meeting on CDC site:

This list of tentative diagnosis agenda topics is not final. The final topics material will be available electronically from the NCHS web site prior to the meeting.

If you are unable to attend the meeting in person there will be conference lines available on the day of the meeting. Individuals do not need to register on line for the meeting if planning to dial in.

NCHS/CMS will be broadcasting the meeting live via Webcast at: http://www.cms.gov/live/

The next meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee is scheduled for March 19–20, 2014. If you are planning to attend the meeting in person you will need to register, online, by March 14.

ICD-10-CM/PCS Coordination and Maintenance Committee Meeting

Public forum to discuss proposed changes to ICD-10-CM and ICD-10-PCS

Wednesday, March 19, 2014 – Thursday, March 2o, 2014

CMS Auditorium, Baltimore, MD

Agendas for the meeting will be posted in February 2014.

If phone lines and live webinar are made available the information will be posted closer to the meeting date.

Day One | Time: 03/19/2014 9:00 AM – 5:00 PM CMS Auditorium

Session: ICD-10-CM/PCS Coordination and Maintenance Committee Meeting
The first day of the meeting, March 19, 2014, will be devoted to procedure code issues.

Day Two | Time: 03/20/2014 9:00 AM – 5:00 PM CMS Auditorium

Session: ICD-10-CM/PCS Coordination and Maintenance Committee Meeting
The second day of the meeting, March 20, 2014 will be devoted to diagnosis code topics.

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The National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS) are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM and draft ICD-10-CM/PCS.

NCHS is also responsible for the development of ICD-10-CM, adapted from the WHO’s ICD-10 for U.S. specific use.

The 2014 release of the draft ICD-10-CM (which replaces the July 2013 release) can be viewed or downloaded here.

ICD-10-CM is scheduled for implementation on October 1, 2014. Until that time the codes in ICD-10-CM are not valid for any purpose or use.

New concepts are added to ICD-10-CM based on the established update process for ICD-9-CM (the ICD-9-CM Coordination and Maintenance Committee) and the World Health Organization’s ICD-10 (the Update and Revision Committee).

Meetings of the Coordination and Maintenance Committee are co-chaired by a representative from NCHS and from CMS. Responsibility for  maintenance of the ICD-9-CM is divided between these two agencies, with classification of diagnoses by NCHS and procedures by CMS.

The name of the Committee will change to the ICD-10-CM/PCS Coordination and Maintenance Committee with the March meeting, as the last updates to ICD-9-CM/PCS took place on October 1, 2013.

Meetings are held twice yearly, in public, at CMS headquarters in Baltimore, MD. The next meeting is scheduled for March 19–20, 2014. The fall meeting is scheduled for September 23–24, 2014.

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Coordination and Maintenance Committee

The Committee provides a public forum to discuss proposed modifications, code changes, updates and corrections to the diagnosis codes in ICD-10-CM and procedural codes in ICD-10-PCS.

Public participation can also take place via phone conference link and live webinar. (Details for both in the Agenda documents.)

Agendas are posted approximately one month prior to the meetings. Diagnostic and procedural proposal Topic Packets, meeting materials, hand outs and presentation slides are posted on the CDC and CMS websites shortly before a meeting.

Up until 2011, transcripts of meeting proceedings were provided. Provision of transcripts is now replaced with videocasts for the full, two-day proceedings, available from the CMS website and posted on YouTube, and a brief Meeting Summary report, available from the CDC site shortly after the meeting.

For attendance in person, prior registration is required, via the CMS meeting registration website. Registration opens approximately one month  prior to a meeting and closes a few days before Day One of a meeting.

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Proposals for modifications, additions, corrections

Suggestions for modifications to ICD-10-CM/PCS come from both the public and private sectors. Since the draft ICD-10-CM is adapted from the WHO’s ICD-10, which is subject to an annual update process, some proposed modifications to ICD-10-CM may reflect updates to the ICD-10.

Interested parties (requestors) must submit proposals for modifications prior to a scheduled meeting and by a specific date. Proposals should be consistent with the structure and conventions of the classification. See Submission of Proposals for submission requirements and proposal samples.

Once proposals have been reviewed, requestors are contacted as to whether their proposal has been approved for presentation at the next Coordination and  Maintenance Committee meeting or not.

Approved proposals are presented at the meetings by representatives for professional bodies, advocacy organizations, clinicians, other professional stakeholders or members of the public with an interest, or are sometimes presented by an NCHS/CMS representative on behalf of a requestor.

No decisions on proposed modifications are made at the meetings. Recommendations and comments are reviewed and evaluated, once the comment period has closed, before final decisions are made.

The Coordination and Maintenance Committee’s role is advisory. All final decisions are made by the Director of NCHS and Administrator of CMS.

Final decisions are made at the end of the year and become effective October 1 of the following year.

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Submitting written comment on proposals presented at meetings

Comments on proposals are invited, at the meeting, at the end of each presentation, or may be submitted in writing following the meeting, during a one to two month duration public comment period.

Addresses for submitting comments are included in the Agenda Topic Packets published before the meetings. NCHS/CMS state that electronic submissions are greatly preferred over snail mail in order to ensure timely receipt of responses.

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Partial code freeze and timing of proposals

According to the Summary of Diagnosis Presentations for the September 18–19, 2013 meeting (for which the comment period closed on November 15):

“Except where noted, all topics are being considered for implementation on October 1, 2015. The addenda items are being considered for implementation prior to October 1, 2014.”

(“ICD-10-CM TABULAR OF DISEASES – PROPOSED ADDENDA” Tabular and Index modification proposals are set out on Diagnosis Agenda Pages 60-66.)

Note that some proposals in the Diagnosis Agenda were requested for insertion in October 2014 as Inclusion Terms to existing codes, with new codes proposed to be created for October 2015, notably, the 6 proposals to insert new DSM-5 disorders into ICD-10-CM presented by Darrel Regier, MD, on behalf of the American Psychiatric Association (Diagnosis Agenda Pages 32-44).

Whether the 17 modifications proposed on Pages 45-46 under “Additional Tabular List Inclusion Terms for ICD-10-CM” which were presented en masse by CDC’s, Donna Pickett, (which include the proposals to add the new DSM-5 “Somatic symptom disorder” and “Illness anxiety disorder” as Inclusion Terms to existing ICD-10-CM F45.x codes) are intended for implementation in October 2014 or in October 2015 is not explicit in the Diagnosis Agenda.

For the September 18–19, 2013 meeting, when submitting written comments, responders were asked to consider the following:

Whether they agree with a proposal, disagree (and why), or have an alternative proposal to suggest. But were also invited to comment on the timing of those proposals that were being requested for approval for October 2014:

Does a request for a new diagnosis or procedure code meet the criteria for implementation in October 2014 during a partial code freeze* based on the criteria of the need to capture a new technology or disease; or should consideration for approval be deferred to October 2015? And separately, to comment on the creation of a specific new code for the condition effective from October 1, 2015 (where requested).

Any code requests that do not meet the criteria [for inclusion during a partial freeze] will be evaluated for implementation within ICD-10-CM on and after October 1, 2015 once the partial freeze has ended and regular (at least annual) updates to ICD-10-CM/PCS resume.

*Partial Code Freeze of Revisions to ICD-9-CM and ICD-10-CM/PCS

  • October  1, 2011 is the last major update of ICD-9-CM. Any further revisions to ICD-9-CM will only be  for a new disease and/or a  procedure  representing new technology.  Revisions will  be posted on this website as addenda (revisions to procedures are posted on  the CMS website).
  • After  October 1, 2011 there will be no further release of ICD-9-CM on CD-ROM.
  • October  1, 2011 is the last major update of ICD-10-CM/PCS until October 1, 2015.
  • Between  October 1, 2011 and October 1, 2015 revisions to ICD-10-CM/PCS will be for new  diseases/new technology procedures, and any minor revisions to correct reported errors in these classifications.
  • Regular (at least annual) updates to ICD-10-CM/PCS will resume on October 1, 2015.

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Public comments not made public

Note that written public comments received by NCHS (Diagnosis) and CMS (Procedural) on proposals requested via these meetings are not aggregated and made publicly accessible. Nor are the names of organizations, professional bodies, individuals or others who have submitted comments listed publicly. It is not possible to scrutinize the number, provenance or substance of the comments received in support of, or in opposition to requests for modifications to ICD-10-CM presented via these meetings. Nor are NCHS/CMS’s rationales for the approval or rejection of requests for modifications to diagnosis or procedural codes on public record.

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September 18–19, 2013 meeting

A substantial number of modifications were proposed via the September 2013 meeting for both procedural and diagnosis codes. These are set out in the Agenda/Topic Packet PDF documents:

Diagnosis Codes Agenda

Procedural Codes Agenda

Meeting Materials

Videocasts for full two day meeting proceedings and Meeting Materials (collated on Dx Revision Watch site)

Summary of Diagnosis Presentations 

The ICD-9-CM timeline (for the remainder of its life) and the ICD-10-CM/PCS timeline are set out on Pages 3-8 of the Diagnosis Agenda.

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Key dates for the forthcoming March 19–20, 2014 meeting

January 17, 2014: deadline for submitting topics to be discussed at the March 19–20, 2014 ICD-10-CM/PCS Coordination and Maintenance Committee (reached).

February 14: registration for attendance opens.

March 14: deadline for registration.

Go here for registration details. (CMS confirmed to me via email on 01.23.13 that the deadline for registration is March 14, not February 14, as incorrectly published in the Diagnosis Agenda timeline.)

April 18, 2014: deadline for receipt of public comments on proposed codes and modifications tabled for March meeting. (Note there is only a 4 week period following this meeting during which written comments can be submitted.)

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Key ICD-10-CM/PCS Timeline dates extracted from full timeline, Pages 3-8, September 18-19, 2013 Diagnosis Agenda

March 19–20, 2014: ICD-10-CM/PCS Coordination and Maintenance Committee meeting.

April 1, 2014: There will be no new ICD-9-CM codes to capture new diseases or technology on April 1, 2014, since the last updates to ICD-9-CM will take place on October 1, 2013.

April 2014: Notice of Proposed Rulemaking to be published in the Federal Register as mandated by Public Law 99-509. This notice will include references to the complete and finalized FY 2015 ICD-10-CM diagnosis and ICD-10-PCS procedure codes. It will also include proposed revisions to the MS-DRG system based on ICD-10-CM/PCS codes on which the public may comment. The proposed rule can be accessed at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html?redirect=/AcuteInpatientPPS/IPPS/list.asp

April 18, 2014: Deadline for receipt of public comments on proposed code [at March meeting.]

June 2014: Final addendum posted on web pages as follows:

Diagnosis addendumhttp://www.cdc.gov/nchs/icd/icd10cm.htm

Procedure addendumhttp://cms.hhs.gov/Medicare/Coding/ICD10/index.html

September 23–24, 2014: ICD-10-CM/PCS Coordination and Maintenance Committee 2014 meeting.

October 1, 2014: New and revised ICD-10-CM and ICD-10-PCS codes go into effect along with DRG changes. Final addendum posted on web pages as follows:

Diagnosis addendumhttp://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

Procedure addendumhttp://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/addendum.html

November 2014: Any new ICD-10 codes required to capture new technology that will be implemented on the following April 1 will be announced. Information on any new codes to be implemented April 1, 2015 will be posted on the following websites:

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/addendum.html

http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

Clarification: Coalition for Diagnostic Rights website

Post #288 Shortlink: http://wp.me/pKrrB-3Dn

Clarification: Coalition for Diagnostic Rights

A website called Coalition for Diagnostic Rights has recently been launched.

The site includes references to Suzy Chapman and to Dx Revision Watch.

Suzy Chapman/Dx Revision Watch is not associated with or affiliated to the Coalition for Diagnostic Rights website or with any organization associated with that site, and has no responsibility for content published on that site, or published in the name of that site on other platforms.

Suzy Chapman
Dx Revision Watch

DSM-5 November Round up #1

Post #285 Shortlink: http://wp.me/pKrrB-3zQ

Recent documents issued by the American Psychiatric Association at DSM-5 Development

Coding Changes Update: Important Coding and Criteria Updates: UPDATED 11/22/13

APA Statement issued 10.31.13: Statement on DSM-5 Text Error Pedophilic disorder text error to be corrected

Text Corrections: DSM-5 Paraphilic Disorders 10/31/13

Criteria Update: Updates to DSM-5 Adjustment Disorders: 10/15/13

Coding Changes Update: Neurocognitive Disorders Coding Updates: UPDATED 10/18/13

Psychiatric News Article: ICD Codes for Some DSM-5 Diagnoses Updated, Mark Moran, 10/7/13

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Commentary, Dx Summit

Attenuated Psychosis Syndrome Was Not Actually Removed from DSM-5

by Sarah Kamens

Note from Dx Revision Watch: Here is another codable diagnosis slipped in by APA before going to press. Between closure of the third DSM-5 draft review and publication of the final code sets a “Brief somatic symptom disorder,” where duration of symptoms is less than 6 months, was added under new category, “Other specified Somatic Symptom and Related Disorder” cross-walked to ICD 300.89 (F45.8) [DSM-5, Page 327]. This “Other specified” category can be used for symptom presentations that do not meet the full criteria for any of the disorders in the Somatic symptom and related disorders diagnostic class.
This means that as little as a single, distressing physical symptom + just one psychobehavioural symptom from the Somatic symptom disorder “B type” criteria, with less than 6 months chronicity would meet criteria for a codable mental disorder. A “Brief illness anxiety disorder” diagnosis of less than 6 months duration has also been inserted under this code – neither of which were in the third draft.

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Commentary from Christopher Lane, Ph.D., at Side Effects, Psychology Today:

The OECD Warns on Antidepressant Overprescribing Antidepressant consumption not matched by an increase in global diagnoses

Christopher Lane | November 22, 2013

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Commentary by Athena Bryan for Brown Political Review:

A Tale of Two Codices: the DSM, ICD and Definition of Mental Illness in America

Athena Bryan | November 21, 2013

Note from Dx Revision Watch: I have added a comment to this article, noting that APA has proposed the following new DSM-5 disorders for inclusion in the forthcoming U.S. specific ICD-10-CM via the September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee: Binge eating disorder (BED); Disruptive mood dysregulation disorder (DMDD); Social (pragmatic) communication disorder; Hoarding disorder; Excoriation (skin picking) disorder; Premenstrual dysphoric disorder (PMDD); that DSM-5′s new constructs, Somatic symptom disorder (SSD) and Illness anxiety disorder were also proposed for insertion into the ICD-10-CM Tabular List and Index; that the ICD-10-CM is a “clinical modification” of WHO’s ICD-10 and is scheduled for U.S. implementation in October 2014; that its development from the ICD-10 has been the responsibility of NCHS.

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Three DSM-5 Somatic symptom disorder related items:

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Editorial British Journal of Psychiatry:

Editorial: Michael Sharpe, DSM-5 Somatic symptom disorder Work Group member BJP November 2013 203:320-321; doi: 10.1192/bjp.bp.112.122523:

Editorial: Somatic symptoms: beyond ‘medically unexplained’

Abstract:

Somatic symptoms may be classified as either ‘medically explained’ or ‘medically unexplained’ – the former being considered medical and the latter psychiatric. In healthcare systems focused on disease, this distinction has pragmatic value. However, new scientific evidence and psychiatric classification urge a more integrated approach with important implications for psychiatry.

Note from Dx Revision Watch: Unless NCHS rejects the proposal submitted at the September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee, Somatic symptom disorder is destined for insertion into the ICD-10-CM Tabular List under F45 Somatoform Disorders as an inclusion term to F45.1 Undifferentiated somatoform disorder and for adding to the Alphabetic Index. See http://wp.me/pKrrB-3×1.

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Slide presentation: Francis Creed, University of Manchester, UK:

Can we now explain medically unexplained symptoms?

Francis Creed | Exeter, June 13, 2013 | PDF format

or open PDF [1.5MB] here Creed June 2013 slide presentation

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Book chapter: Polypharmacy in Psychiatry Practice, Volume I: Multiple Medication Use Strategies:

Polypharmacy in Psychiatry Practice, Volume I: Multiple Medication Use Strategies, Ritsner, Michael S (Ed.) 2013, XVII, 287 p ISBN: 978-94-007-5804-9 (Print) 978-94-007-5805-6 (Online)

Chapter 11: Multiple Medication Use in Somatic Symptom Disorders: From Augmentation to Diminution Strategies  

Most of Chapter 11, Pages 243-254 (pp 247-249 omitted) can be previewed on Google Books here

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