Rapid Responses to Allen Frances’ BMJ opposition piece on DSM-5‘s ‘Somatic Symptom Disorder’

Post #230 Shortlink:
http://wp.me/pKrrB-2HN

Update March 28: Currently 27 BMJ Rapid Responses have been published. BMJ has also launched a Poll asking readers to vote on: “Will the new DSM-5 lead to patients being mislabelled as mentally ill?” Vote on this page

Update March 26: a tautology that serves no useful purpose… 1 Boring Old man on SSD

On March 20, BMJ published a commentary on the DSM-5 ‘Somatic Symptom Disorder’ by Allen Frances, MD, with contribution from Dx Revision Watch, strongly opposing the inclusion of this new, poorly tested disorder in the forthcoming DSM-5, scheduled for publication on May 22.

Dr Frances is professor emeritus, Duke, and had chaired of the Task Force for DSM-IV.

Article here:

PERSONAL VIEW

The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill

This new condition suggested in the bible of mental health diagnoses lacks specificity, says Allen Frances

The opinion piece is also featured in this week’s “Editor’s Choice”:

Editor’s Choice
US Editor’s Choice

DSM-5 and the rough ride from approval to publication

Edward Davies, US news and features editor, BMJ

Rapid Responses to the BMJ article can be read here:

http://www.bmj.com/content/346/bmj.f1580?tab=responses

24 Rapid Responses have been published. I am publishing both my submissions, below:

Suzy Chapman
Patient advocate

27 March 2013

What evidence for safety of application of SSD in children?

Extracts from Somatic Symptom Disorders Work Group ‘Disorders Description’ document, published May 2011, for the second DSM-5 stakeholder review [1]:

“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.”

“PFAMC [Psychological Factors Affecting Medical Condition]* can occur across the lifespan. Particularly with young children, corroborative history from parents or school can assist the diagnostic evaluation.”

“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, then, that the ‘B type’ Somatic Symptom Disorder (SSD) criteria are intended for application where the parent(s) of a child with chronic somatic symptoms are perceived to be expressing ‘excessive thoughts, feelings, and behaviors,’ or ‘disproportionate and persistent concerns,’ or ‘maladaptive’ coping strategies; or considered to be devoting ‘excessive time and energy’ to [a child's] symptoms or health concerns or demonstrating ‘dysfunctional and maladaptive beliefs’ about symptoms or disease.

There is no evidence that SSD or PFAMC have been field tested by APA or by any other group for safety and reliability of application in children and young people.

If the finalized criteria sets and texts for this section allow for the application of a diagnosis of Somatic Symptom Disorder where a parent is considered to be excessively concerned with a child’s symptoms, families caring for children with any chronic disease or condition may be placed at risk of wrongful accusation of ‘over-involvement’ with a child’s symptomatology.

Where a parent is perceived as enabling ‘maintenance of sick role behaviour’ in a child or young person this can provoke a devastating cascade of intervention: placement or threat of placement on the ‘at risk register’; social services and child protection investigation; in some cases, court intervention for removal of a sick child out of the home environment and into foster care or for enforced in-patient rehabilitation against the wishes of the family.

This is already happening in the UK, USA and currently in Denmark, in families with a child or young person with chronic illness or disability, notably with Chronic Fatigue Syndrome or ME. It may happen more frequently in families where a diagnosis of chronic childhood illness + SSD has been applied.

This section of DSM-5, seemingly overlooked by clinicians in the field, both within and outside psychiatry and psychosomatics and by medico-legal and disability specialists demands urgent scrutiny and investigation.

*Note: In DSM-IV-TR, PFAMC is located in the Appendix under ‘Other Conditions That May Be a Focus of Clinical Attention.’ For DSM-5, PFAMC is being relocated to the mental disorders classifications and coded under the new section ‘Somatic Symptoms and Related Disorders’ that replaces DSM-IV-TR’s ‘Somatoform Disorders.’

References:

1 Somatic Symptom Disorders Work Group ‘Disorders Description’ document, second stakeholder review, May 2011

Competing interests: I reviewed and provided comment and suggestions for this BMJ commentary by Allen Frances, MD. I run a website that archives and reports on DSM-5 and ICD-11 activities.

+++
Suzy Chapman
Patient advocate

26 March 2013

Dichotomy

I am puzzled by the disconnect between the cautiousness expressed within this 2011 article by Dr Dimsdale [1] and his work group’s barrelling through with a new construct, which James Phillips notes [2] lacks a high level of empirical support.

Dr Dimsdale is evidently aware of the perils of over diagnosing mental illness and identifies inter alia that a number of factors influence the accuracy of diagnoses: that one must consider how thorough was the physician’s evaluation; how adequate the physician’s knowledge base in synthesizing the information obtained from the history and physical examination; that time pressures in primary care make it difficult to comprehensively evaluate patients and thus contribute to delays and slips in diagnosis; that physicians can wear blinders or have tunnel vision in evaluating patients – that just because a patient has previously had MUS [Medically Unexplained Symptoms] that there is no guarantee that the patient has yet another MUS; that diagnoses are shaped by the state of medical knowledge at the time when the patient is evaluated; that new diseases are constantly arising; that aetiologies are eventually established for diseases that have previously not been well understood.

Yet the group is proposing to operationalize an entirely new disorder of its own devising, using highly subjective criteria for which no significant body of research into reliability, validity and safety has been published, that will capture adults, children, adolescents and elderly people with diverse illnesses.

Whilst it was welcomed that for the third iteration, the chronicity criteria of “greater than one month” was removed with the merging of SSSD [Simple Somatic Symptom Disorder] with CSSD  [Complex Somatic Symptom Disorder], it is of considerable concern that in order to accommodate SSSD within the CSSD criteria, the “B type” threshold has been reduced from “at least two” to “at least one,” thereby potentially increasing prevalence.

It is also of considerable concern that no data on prevalence estimates were available for the second and third draft review and no data on impact of different thresholds for the “B type” criteria.

In light of the field trial findings, it is also of concern that the SSD work group has yet to publish any projections for prevalence estimates and the potential increase in mental health diagnoses across the entire disease landscape, nor on the projected clinical and economic burden of providing CBT and similar therapies for patients for whom an additional diagnosis of Somatic Symptom Disorder is assigned.

Given the majority of mental health disorders are diagnosed and treated within primary care and non-psychiatric settings, it is remarkable that the Task Force failed to recruit any general practitioners or clinicians outside the field of psychiatry and psychosomatics to serve on this work group, nor a medico-legal specialist.

In a counterpoint response to Allen Frances’ May 2012 New York Times Op-Ed piece, the American Psychiatric Association (APA) stated:

“…There are actually relatively few substantial changes to draft disorder criteria. Those that have been recommended are based on the scientific and clinical evidence amassed over the past 20 years and then are subject to multiple review processes within the APA.”

The Somatic Symptom and Related Disorders chapter is one section for which substantial changes to existing definitions and criteria are being introduced but with no body of rigorous evidence to support the SSD construct – a construct already influencing proposals for a new ICD classification, “Bodily Distress Disorder” for the World Health Organization’s ICD-11 and ICD-11-PHC (primary care) version, to replace several of ICD-10′s existing Somatoform Disorder categories.

During the second public review of draft criteria for DSM-5, the ‘Somatic Symptom Disorder’ section received more submissions from advocacy organizations, patients, and professionals than almost any other disorder category. But rather than tighten up the criteria or subject the entire disorder section to independent scientific review, the SSD Work Group’s response was to lower the threshold even further – potentially pulling even more patients under a mental disorder label.

In February, Dr Dimsdale told journalist, Susan Donaldson James, for ABC News:

“…If it doesn’t work, we’ll fix it in the DSM-5.1 or DSM-6.” [3]

APA says there will be opportunities to reassess and revise DSM-5′s new disorders, post publication, and that it intends to start work on a DSM-5.1 release. Patient groups, advocates and professionals are not reassured by APA’s ‘publish first – patch later’ approach to science.

Dr Dimsdale has described his group’s revision as “a step in the right direction.” But DSM-5 appears hell bent on stumbling blindly from the “treacherous foundation” of ‘medically unexplained’ into the quicksands of loose, unvalidated constructs.

The appropriate response would be for APA to pull this disorder out of the main diagnostic section, now, before its new manual rolls off the presses and relocate under the “V codes.”

1 Dimsdale JE. Medically unexplained symptoms: a treacherous foundation for somatoform disorders? Psychiatr Clin North Am 2011;34:511-3.

2 BMJ Rapid Response:
http://www.bmj.com/content/346/bmj.f1580/rr/637773

3 New Psych Disorder Could Mislabel Sick as Mentally Ill, Susan Donaldson James, ABC News, February 2013.

Competing interests: I reviewed and provided comment and suggestions for this BMJ commentary by Allen Frances, MD. I run a website that archives and reports on DSM-5 and ICD-11 activities.

Related content

The President’s Message in the Spring edition of The National Forum, newsletter of the National CFIDS Foundation Inc. (Vol. 18, No. 4 Spring 2013) is devoted to the DSM-5 SSD issue and can also be read here on their website.

Allen Frances, MD, blogs at DSM 5 in Distress, and Saving Normal at Psychology Today.

Mislabeling Medical Illness As Mental Disorder December 8, 2012

Bad News DSM-5 Refuses To Correct Somatic Symptom Disorder January 16, 2013

For additional commentary on ‘Somatic Symptom Disorder’:

Somatic Symptom Disorder could capture millions more under mental health diagnosis by Suzy Chapman for Dx Revision Watch, May 26, 2012