‘Somatic Symptom Disorder’ in Current Biology, 22 April, 2013

‘Somatic Symptom Disorder’ in Current Biology

Post #238 Shortlink: http://wp.me/pKrrB-2NG

The April 22 edition of Current Biology publishes a feature article on DSM-5 by science writer, Michael Gross, Ph.D.

The article includes quotes from Suzy Chapman and Allen Frances on the implications for diverse patient groups for the introduction of the new Somatic Symptom Disorder into the next edition of the DSM, scheduled for release in May.

The article also mentions the influence of Somatic Symptom Disorder on proposals for a new ICD category – Bodily Distress Disorder – being field tested for ICD-11 and ICD-11-PHC [1].

…Chapman and Frances are concerned that the new definition of SSD will also be reflected in ICD-11. ICD-11 is field testing a new category Bodily Distress Disorder proposed to replace six or seven existing ICD-10 somatoform disorders, which, according to working group reports on emerging proposals, mirrors the DSM-5 somatic symptom disorder definition, says Chapman.

The article can be read in full at:

Current Biology 22 April, 2013 Volume 23, Issue 8

Copyright 2013 All rights reserved. Current Biology, Volume  23, Issue  8, R295-R298, 22 April 2013
doi:10.1016/j.cub.2013.04.009

Feature

Has the manual gone mental?

Michael Gross

Full text: http://www.cell.com/current-biology/fulltext/S0960-9822(13)00417-X

PDF: http://download.cell.com/current-biology/pdf/PIIS096098221300417X.pdf

1 ICD-11 Beta drafting platform: Chapter 5: Bodily Distress Disorder: Mild; Moderate; Severe

Three BMJ letters published in response to Somatic Symptom Disorder commentary

Three letters are published this week in response to Allen Frances’ BMJ commentary on ‘Somatic Symptom Disorder’

Post #237 Shortlink: http://wp.me/pKrrB-2No

On March 19, BMJ published a commentary by Allen Frances, MD, with contribution from Suzy Chapman, in both the print and online editions, strongly opposing the inclusion of ‘Somatic Symptom Disorder’ in the forthcoming DSM-5:

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 was also featured as US Editor’s Choice:

DSM-5 and the rough ride from approval to publication
Edward Davies, US news and features editor, BMJ

BMJ press released the commentary which was picked up by a number of international media sites including UK Times and Deborah Brauser for Medscape Medical News. To date, 31 Rapid Responses have been received.

Three letters (all US respondents) are printed in this week’s BMJ print edition (20 April 2013 Vol 346, Issue 7904). The letters are behind a paywall so I am giving links to the original BMJ Rapid Responses, with the caveat that responses may have been edited for the print edition:

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LETTERS
New somatic symptom disorder in DSM-5

Helping to find the most accurate diagnosis

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2228 (Published 16 April 2013) BMJ 2013;346:f2228
Joel E Dimsdale, professor of psychiatry emeritus, Michael Sharpe, professor of psychiatry, Francis Creed, professor of psychiatry, DSM-5 Somatic Symptom Disorders work group  BMJ Rapid Response 20 March 2013

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Guilty of diagnostic expansion

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2254 (Published 16 April 2013) BMJ 2013;346:f2254
James Phillips, psychiatrist, USA  BMJ Rapid Response 25 March 2013

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A step in the wrong direction

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2233 (Published 16 April 2013) BMJ 2013;346:f2233
Steven A King, chair, DSM-IV and DSM-IV-TR pain disorders committees; Pain Management and Psychiatry, New York  BMJ Rapid Response 28 March 2013

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Further reading:

Somatic Symptom Disorder could capture millions more under mental health diagnosis Suzy Chapman, May 26, 2012
Mislabeling Medical Illness As Mental Disorder Allen Frances, MD, Psychology Today, DSM 5 in Distress, December 8, 2012
Why Did DSM 5 Botch Somatic Symptom Disorder? Allen Frances, MD, Psychology Today, Saving Normal, February 6, 2013
New Psych Disorder Could Mislabel Sick as Mentally Ill Susan Donaldson James, ABC News, February 27, 2013
Dimsdale JE. Medically unexplained symptoms: a treacherous foundation for somatoform disorders? Psychiatr Clin North Am 2011;34:511-3. [PMID: 21889675]

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American Psychiatric Association justifications for SSD:

APA Somatic Symptom Disorder Fact Sheet 
Somatic Chapter Drops Centrality Of Unexplained Medical Symptoms Psychiatric News, Mark Moran, March 1, 2013
Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care David J Kupfer, MD, Chair, DSM-5 Task Force, defends the SSD construct, Huffington Post, February 8, 2013

DSM-5 publication date May 22: American Psychiatric Association to release DSM-5 between May 18-22, San Francisco

Post #235 Shortlink: http://wp.me/pKrrB-2Lq

DSM-5 publication date May 22: American Psychiatric Association to release DSM-5 between May 18-22, San Francisco

After 14 years and with a staggering $25 million thrown at it, the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will be launched during the American Psychiatric Association’s (APA) Annual Meeting in San Francisco, May 18-22, 2013.

The Bumper Book of Head Stuff has cost $25,000 a page.

“…ignore DSM 5. It is not official. It is not well done. It is not safe. Don’t buy it. Don’t use it. Don’t teach it.”

Commentary: “Does DSM 5 Have a Captive Audience?” Saving Normal, Allen Frances, MD

Further revisions and refinements to the criteria sets and disorder descriptions, following closure of the third and final stakeholder review and comment period (June 15, 2012) and the finalizing of texts in December and January, are embargoed and won’t be evident until the manual is released, next month.

Draft proposals, as they had stood on the DSM-5 Development site for the third stakeholder review, were removed from the APA’s website last November. Additional pages archiving draft proposals for DSM-5 Development internal use which remained publicly accessible were put behind a webmaster log in, around mid March.

(No drafts of the expanded texts that accompany the disorder sections and categories have been available for public scrutiny at any stage in the drafting process.)

The official publication date for DSM-5 is May 22 for the U.S. (May 31 for UK). The manual is 1000 pages and costs nearly $200 for the hardcover edition. An electronic version of the DSM-5 is understood to be in development for later this year.

According to this December 1 interview with Task Force Chair, David J Kupfer, MD, for the Washingtonian,

…While it will likely be some time before we can expect a DSM-6, it may only be a few years until a DSM-5.1 or -5.2, thanks to the expected digital version of the manual. “We don’t wait to wait another 19 to 20 years to have a new revision of the whole volume,” says Kupfer. “But if there is some unexpected consequence, which we can’t anticipate, we have an opportunity to fix something two to three years from now.”

A DSM-5 Table of Contents listing the new disorder sections and category names for DSM-5 (but not the criteria sets) can be accessed on this APA page.

Also at that URL – fact sheets, articles and videos for selected categories, which are being added to every few weeks (including justifications for some of the more controversial changes and new inclusions), and the following documents relating to the overall development process:

Insurance Implications of DSM-5 (New document)
Highlights of Changes from DSM-IV-TR to DSM-5 (updated April 5, 2013)
From Planning to Publication: Developing DSM-5
The Organization of DSM-5
The People Behind DSM-5

A number of books are publishing around the DSM-5 this April and May:

The Intelligent Clinician’s Guide to the DSM-5® by Joel Paris (Apr 17, 2013)

The Book of Woe: The DSM and the Unmaking of Psychiatry by Gary Greenberg  (May 2, 2013) (also available as an Audio Book and Audio CD)

Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life by Allen Frances (May 14, 2013)

Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5 by Allen Frances MD (May 17, 2013)

Making the DSM-5: Concepts and Controversies by Joel Paris and James Phillips (May 31, 2013)

Recent press releases

December 1, 2012: APA Release No. 12-43 American Psychiatric Association Board of Trustees Approves DSM-5 (includes Attachment A: Select Decisions Made by APA Board of Trustees)

January 18, 2013: APA Release No. 13-06 DSM-5 Now Available for Preorder

February 28, 2013:  APA Release No. 13-11 APA Annual Meeting in San Francisco, May 18-22; DSM-5 to be Released

April 9, 2013: APA Release No. 13-19 APA 2013 Annual Meeting Special Track to Present DSM-5 Changes

DSM and DSM-5 are registered trademarks of the American Psychiatric Association.

Many faces of somatic symptom disorders, International Review of Psychiatry

Many faces of somatic symptom disorders, International Review of Psychiatry February 2013

Post #234 Shortlink: http://wp.me/pKrrB-2Kl

Cavia15

Buried within the ‘Disorders Description’ document, published with the Somatic Symptom Disorders Work Group proposals for the second DSM-5 stakeholder review, are three brief references to children:

“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.” [1]

1 Somatic Symptom Disorders Work Group ‘Disorders Description’ document, Second draft review, May 2011

APA evidently intends its new Somatic Symptom Disorder for application in children with chronic, distressing symptoms; or where the parent of a child with chronic, distressing symptoms is perceived to be expressing ‘disproportionate and persistent concerns,’ or ‘maladaptive’ coping strategies, or devoting ‘excessive time and energy’ to [a child's] symptoms or health concerns or demonstrating ‘dysfunctional and maladaptive beliefs’ about symptoms or disease.

The finalized texts that expand on disorder descriptions in the DSM-5 manual are under embargo and it won’t be known until May what guidance (if any) is included for practitioners for the application of SSD and PFAMC in children and adolescents.

But there are no specific references, guidance or cautions for the application of SSD or PFAMC in children within the draft criteria sets, as they had stood at the last stakeholder review, nor within the proposals and brief rationale texts published with the third draft.

And there are no specific references to the application of PFAMC in children, or SSD in children and parents within the APA’s Somatic Symptom Disorder Fact Sheet or the Highlights of Changes from DSM-IV-TR to DSM-5 document, or in this Mark Moran Psychiatric News article justifying the proposals.

Not surprising, then, that the use of this new SSD construct in children and young people, or as applied to the parent(s) of a child with chronic somatic symptoms has received little discussion within the field or in the advocacy arena.

In DSM-IV-TR, PFAMC was listed under ‘Other Conditions That May Be a Focus of Clinical Attention.’ For DSM-5, APA has approved the shifting of PFAMC “from its obscure place in the back of prior DSM editions into the Somatic Symptom Disorders chapter” where it now attracts a mental disorder code. (Another issue that has attracted scant attention.)

What evidence for safety of application of SSD in children?

Very little is known about the APA’s field trials for what was at that point known as ‘CSSD’ (Complex Somatic Symptom Disorder). There is no publicly available information on patient selection or study design.

The make-up of the three field trial study groups was presented at conference as: a ‘diagnosed illness’ group (n=205), comprising patients with cancer or coronary disease; a ‘functional somatic’ group (n=94), comprising patients with irritable bowel syndrome and ‘chronic widespread pain’ (a term often used as an alternative to ‘fibromyalgia’; and a considerably larger ‘healthy’ control group.

There is no evidence that either SSD or PFAMC has been field tested by APA or investigated by any other group for safety and reliability of application in children and young people – an issue raised in my recent BMJ Rapid Response: What evidence for safety of application of SSD in children? March 27, 2013.

The lack of a body of rigorous evidence to support the validity and safety of the new SSD construct in adults (and especially in older patients who are more likely to be living with multiple age onset diseases and subject to polypharmacy and the potential for somatic symptoms resulting from medication side effects or drug interactions) is disturbing.

Joel Dimsdale’s insouciant, “If it doesn’t work, we’ll fix it in the DSM-5.1 or DSM-6″ is particularly disturbing in the absence of evidence for the safety and validity of the application of SSD in children and adolescents.

For ICD-11, the current proposal is to replace or subsume six or seven existing ICD-10 Somatoform Disorder categories with a new category, Bodily Distress Disorder. According to emerging proposals for ICD-11-PHC (the primary care version of ICD-11), BDD is proposed to include DSM-5‘s new [C]SSD [1] [2].

Does ICD-11 intend its proposed BDD to be applied to children and adolescents? On what evidence does the ICD-11 working group for the revision of ICD-10′s Somatoform Disorders, the Topic Advisory Group for Mental Health, the ICD-11 Revision Steering Group and WHO classification experts rely for the validity of BDD as a construct and its application in children?

1 Goldberg DP. Comparison between ICD and DSM diagnostic systems for mental disorders. In: Sorel E, ed. 21st century global mental health. Jones & Bartlett Learning, 2012:37-53. Free Sample Chapter 2: Page 50
2 Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry 2012;24:556-67. PMID:23244611

Other than the two papers, below, I have yet to find any other papers which reference or specifically discuss the operationalization of the SSD criteria in children and adolescents.

Schulte IE, Petermann F: Somatoform disorders: 30 years of debate about criteria! What about children and adolescents? J Psychosom Res 2011; 70:218-228. [PMID: 21334492] Abstract

“The aim of this study was to evaluate the suitability of the complex somatic symptom disorder, proposed by the DSM-V Somatic Symptom Disorders Workgroup, in classifying children and adolescents who suffer severely from medically unexplained symptoms.”

That paper is cited by this 2012 paper, below, for which a full PDF is available:

http://www.hdbp.org/psychiatria_danubina/pdf/dnb_vol24_no4/dnb_vol24_no4_353.pdf

Ghanizadeh, G, Ali Firoozabadi, A. A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V. Psychiatria Danubina 12/2012; 24(4):353-8.

which addresses a question, “Is it suitable for children and adolescents?” under “SOME OTHER CHANGES AND CONCERNS ABOUT NEW CLASSIFICATION”

If readers are aware of other papers discussing the application of SSD in children I’d be pleased to have information.

Many faces of somatic symptom disorders, International Review of Psychiatry February 2013

As far as one can tell from the abstracts, none of the recently published papers below appears to discuss the application of the new SSD diagnosis in children, young people and families:

A free access editorial and abstracts for 11 papers in the February issue of International Review of Psychiatry:

http://informahealthcare.com/toc/irp/25/1

Volume 25, Number 1 (February 2013) Somatic Symptoms Disorders

Please refer to site for links to free Abstracts and subscription papers.

GUEST EDITOR: Santosh K. Chaturvedi

Editorial
Many faces of somatic symptom disorders
Santosh K. Chaturvedi

International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 1–4.

Free PDF Plus: http://informahealthcare.com/doi/pdfplus/10.3109/09540261.2012.750491

——————————————————————————–
Somatic symptom disorders and illness behaviour: Current perspectives
Kirsty N. Prior, Malcolm J. Bond
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 5–18.
——————————————————————————–
Diagnostic criteria for psychosomatic research and somatic symptom disorders
Laura Sirri, Giovanni A. Fava
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 19–30.
——————————————————————————–
Measurement and assessment of somatic symptoms
Santosh K. Chaturvedi, Geetha Desai
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 31–40.
——————————————————————————–
Somatization and somatic symptom presentation in cancer: A neglected area
Luigi Grassi, Rosangela Caruso, Maria Giulia Nanni
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 41–51.
——————————————————————————–
Somatic symptoms in consultation-liaison psychiatry
Sandeep Grover, Natasha Kate
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 52–64.
——————————————————————————–
Association of somatoform disorders with anxiety and depression in women in low and middle income countries: A systematic review
Rahul Shidhaye, Emily Mendenhall, Kethakie Sumathipala, Athula Sumathipala, Vikram Patel
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 65–76.
——————————————————————————–
‘I’m more sick than my doctors think’: Ethical issues in managing somatization in developing countries
Prabha S. Chandra, Veena A. Satyanarayana
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 77–85.
——————————————————————————–
Review of somatic symptoms in post-traumatic stress disorder
Madhulika A. Gupta
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 86–99.
——————————————————————————–
Somatic symptoms in primary care and psychological comorbidities in Qatar: Neglected burden of disease
Abdulbari Bener, Elnour E. Dafeeah, Santosh K. Chaturvedi, Dinesh Bhugra
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 100–106.
——————————————————————————–
Psychopharmacotherapy of somatic symptoms disorders
Bettahalasoor Somashekar, Ashok Jainer, Balaji Wuntakal
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 107–115.
——————————————————————————–
Behavioural and psychological management of somatic symptom disorders: An overview
Mahendra P. Sharma, M. Manjula
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 116–124.

Rapid Responses to BMJ DSM-5 ‘Somatic Symptom Disorder’ opposition piece

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.

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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

‘Somatic Symptom Disorder’ – the most ubiquitous mental health diagnosis you never heard of

‘Somatic Symptom Disorder’ – the most ubiquitous mental health diagnosis you never heard of

Lead psychiatrist for DSM-IV voices opposition to DSM-5′s new ‘catch-all’ criteria in BMJ, today

Post #229 Shortlink: http://wp.me/pKrrB-2GI

Update: Rapid Responses to the BMJ article can be read here:

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

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The opinion piece published under BMJ’s “Personal View” section, on Wednesday, is now featured in this week’s “Editor’s Choice”:

http://www.bmj.com/content/346/bmj.f1918

Editor’s Choice
US Editor’s Choice

DSM-5 and the rough ride from approval to publication

BMJ2013;346doi: http://dx.doi.org/10.1136/bmj.f1918 (Published 22 March 2013)

Edward Davies, US news and features editor, BMJ

Update: Media coverage for BMJ article:

Times of India

Eat or surf a lot? You risk being labelled mentally ill

Malathy Iyer, TNN | Mar 24, 2013

…Earlier this week, American psychiatrist Allen Frances, who helped devise the fourth edition of the manual (DSM-IV), lashed out against the new installment in the British Medical Journal. “It risks mislabelling a sizeable number of population as mentally ill,” Frances wrote.

He is disturbed about a new introduction called ‘somatic symptom disorder’ that will need only one bodily symptom distressing or disrupting daily life for about six months. “This new category will extend the scope of mental disorder classification by eliminating the requirement that somatic symptoms must be medically unexplained,” he wrote. In a field trial study to check for somatic symptom disorder, the results included 15% of patients with cancer or heart disease and 26% with irritable bowel syndrome or fibromyalgia. “The rate of psychiatric disorder among medically ill patients is unknown, but these rates seem high,” added Frances.

Doctors in India are not too supportive of the somatic symptom disorder…

+++
Medscape Medical News > Psychiatry

DSM-5 Somatic Symptom Disorder Debate Rages On

Deborah Brauser | March 21, 2013

The inclusion of the new somatic symptom disorder category in the soon-to-be-released Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) continues to spark heated debate in the field of psychiatry.

In a “Personal View” published online March 19 in BMJ, Allen Frances, MD, writes that the new disorder could result in “inappropriate diagnoses of mental disorder and inappropriate medical decision making” and urged clinicians to ignore the category completely…

…”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,” he writes.

“Every diagnostic decision is a delicate balancing act between definitions that will result in too much versus too little diagnosis — the DSM-5 work group chose a remarkably sensitive definition that is also remarkably non-specific.”

He adds that clinicians should just ignore this classification altogether…

(Free registration for access to full article.)

Rheumatology Update

New ‘somatic symptom disorder’ captures fibromyalgia

Tony James | March 22, 2013

The new diagnosis of ‘somatic symptom disorder’ due for inclusion in the American Psychiatric Association’s updated diagnostic manual will capture up to a quarter of fibromyalgia patients…

Psychiatry Update (Australia)

Clinicians urged to ignore DSM-5 ‘somatic symptom disorder’

Tony James | March 20, 2013

The chair of the DSM-IV task force has told clinicians to ignore the new diagnosis of ‘somatic symptom disorder’ in DSM-5.

In a strongly-worded critique in this week’s BMJ, Professor Frances said that every diagnostic decision was a delicate balancing act between over-diagnosis and under-diagnosis…

“…The diagnosis of somatic symptom disorder is based on subjective and difficult to measure cognitions that will enable a ‘bolt-on’ diagnosis of mental disorder to be applied to all medical conditions, irrespective of cause.”

Field trials had shown that the new definition captured 15% of patients with cancer or heart disease and 26% with irritable bowel syndrome or fibromyalgia.

(Registered Medical Practitioner site; registration required for access to full article.)

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Inform 21

Un nuevo trastorno podría clasificar a millones de personas como enfermos mentales

March 21, 2013

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UK Times

The Times Mental Health

Psychologists to fight new list of mental illnesses

Martin Barrow, Health Editor | March 21, 2013

Everyday Health

Why Obsessing Over Physical Symptoms Could Equal Mental Illness

A psychiatrist argues in a new paper that a change in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) could lead to misdiagnosis of people with cancer and heart disease as mentally ill.

Jaimie Dalessio | Everyday Health Staff Writer | March 20, 2013

Come May, everyone with chronic medical illness or long-term pain – from cancer to coronary disease, MS to myalgia, becomes a potential candidate for a new mental health label.

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On Wednesday, BMJ publishes a commentary on the DSM-5 ‘Somatic Symptom Disorder’ by Allen Frances, MD, who chaired the Task Force for DSM-IV, with contribution from Dx Revision Watch:

http://www.bmj.com/uk/comment

Full article available without subscription, here:

http://www.bmj.com/content/346/bmj.f1580

PDF here:

http://www.bmj.com/highwire/filestream/636761/field_highwire_article_pdf/0/bmj.f1580.full.pdf

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

Allen Frances chair of the DSM-IV task force

The 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…

BMJ Media release will be available here:

http://group.bmj.com/group/media/latest-news

Psychiatric creep

For DSM-5, the somatoform disorders section is being dismantled and four rarely used disorders are being replaced by a single new diagnosis, ‘Somatic Symptom Disorder.’

Out go DSM-IV’s rigorous criteria sets and the requirement for multiple symptoms to be medically unexplained; in comes a far looser definition that doesn’t distinguish between ‘medically unexplained’ symptoms or somatic symptoms in association with diagnosed medical illness.

From May, patients with common diseases like cancer, angina, diabetes or multiple sclerosis; with long-term pain, chronic illnesses like irritable bowel syndrome, fibromyalgia or CFS, or with unexplained conditions that have so far presented with somatic (bodily) symptoms of unclear cause may qualify for an additional mental disorder diagnosis of ‘Somatic Symptom Disorder’ if the clinician considers they also meet the criteria for ‘Somatic Symptom Disorder,’ and may benefit from treatment.

The SSD criteria set focuses on the psychological impact of persistent, distressing bodily symptoms on the patient’s thoughts, feelings and behaviors and the degree to which their response is considered ‘disproportionate’ or ‘excessive.’

As the criteria stand, this new disorder will potentially result in a ‘bolt-on’ mental health diagnosis being applied to all chronic illnesses and medical conditions if the clinician decides the patient’s response to distressing symptoms is ‘excessive’ or their coping strategies are ‘maladaptive,’ or that they are ‘catastrophising’ or displaying ‘fear avoidance.’ Or if the practitioner feels the patient is spending too much time on the internet researching data, symptoms and treatments, or that their lives have become ‘dominated’ by ‘illness worries,’ they may be vulnerable to an additional diagnosis of SSD.

Patients with chronic, multiple bodily symptoms due to rare conditions or multi-system diseases like Behçet’s syndrome or Systemic lupus, which may take several years to diagnose, will also be vulnerable to misdiagnosis with a mental disorder.

There is no substantial body of research to support the validity, reliability or safety of the ‘Somatic Symptom Disorder’ diagnosis.

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 has been to lower the threshold even further – potentially pulling even more patients under a mental disorder label.

The ‘Somatic Symptom Disorder’ Work Group rejected eleventh hour calls from professionals and patients to review its criteria before going to print.

APA says there will be opportunities to reassess and revise DSM-5s 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 a ‘publish first – patch later’ approach to science.

Notes for media, websites, bloggers:

1. The next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be published by American Psychiatric Publishing Inc. in May 2013. It will be known as ‘DSM-5′ and has been under development since 1999.
http://www.dsm5.org/Pages/Default.aspx
http://www.dsm5.org/Documents/DSM%205%20development%20factsheet%201-16-13.pdf

2. The American Psychiatric Association (APA) has spent $25 million on the development of DSM-5.

3. The Diagnostic and Statistical Manual of Mental Disorders is used by mental health and medical professionals for diagnosing and coding mental disorders. It is used by psychiatrists, psychologists, therapists, counselors, primary health care physicians, nurses, social workers, occupational and rehabilitation therapists and allied health professionals.

The DSM is also used for medical insurance reimbursement and informs government, public health policy, courts and legal specialists, education, forensic science, prisons, drug regulation agencies, pharmaceutical companies and researchers. Diagnostic criteria defined within DSM determine what is considered a mental disorder and what is not, which treatments and therapies health insurers will authorise funding for, and for how long.

4. Four existing disorder categories in the DSM-IV ‘Somatoform Disorders’ section: somatization disorder [300.81], hypochondriasis [300.7], pain disorder, and undifferentiated somatoform disorder [300.82] will be eliminated and replaced with a single new category – ‘Somatic Symptom Disorder’ for DSM-5.

5. APA has held three stakeholder comment periods during which professional and public stakeholders have been invited to submit comment on the proposals for the revision of DSM-IV categories and criteria (in February-April 2010; May-June 2011; May-June 2012).

6. DSM-5 is slated for release at the American Psychiatric Association’s 166th Annual Meeting, San Francisco (May 18-22, 2013). The new manual is available for pre-order and will cost $199: http://www.psychiatry.org/dsm5

7. Allen Frances, MD, was chair of the DSM-IV Task Force and of the Department of Psychiatry at Duke University School of Medicine, Durham, NC; Dr Frances is currently professor emeritus, Duke.

8. Dr Frances blogs at DSM 5 in Distress, and Saving Normal at Psychology Today.

Mislabeling Medical Illness As Mental Disorder was published on December 8, 2012

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

For additional information 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

Suzy Chapman

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