Erasing the interface between psychiatry and medicine (DSM-5)

Erasing the interface between psychiatry and medicine (DSM-5)

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Under the guise of “eliminating stigma” and eradicating “terminology [that] enforces a dualism between psychiatric and medical conditions” the American Psychiatric Association (APA) appears hell bent on colonising the entire medical field by licensing the application of a mental health diagnosis to all medical diseases and disorders.

While a stream of often acerbic commentaries from two former DSM Task Force chairs, Allen Frances and Robert Spitzer, have focused on the implications for introducing new additions into the DSM and broadening the definitions of existing diagnostic criteria, the DSM-5 “Somatic Symptom Disorders” Work Group (Chair, Joel E Dimsdale) has been quietly redefining DSM’s “Somatoform Disorders” categories with proposals that if approved, would legitimise the application of an additional diagnosis of “Somatic Symptom Disorder” to all medical diseases and disorders.

Radical proposals for renaming the “Somatoform Disorders” category “Somatic Symptom Disorders” and combining a number of existing categories under a new rubric, “Complex Somatic Symptom Disorder (CSSD)”, and a more recently proposed “Simple Somatic Symptom Disorder (SSSD)”, have the potential for bringing millions more patients under a mental health banner and expanding markets for psychiatric services, antidepressants, antipsychotics and behavioural therapies such as Cognitive Behavioural Therapy (CBT) for the “modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors” for all patients with somatic symptoms, irrespective of cause.

In a June ’09 Editorial, titled “The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report”, which expanded on a brief DSM-5 Work Group progress report published on the DSM-5 Development website that April, Joel E Dimsdale and fellow DSM-5 Work Group member, Francis Creed, reported that by doing away with the “controversial concept of medically unexplained symptoms”, their proposed classification might diminish the “dichotomy, inherent in the ‘Somatoform’ section of DSM IV, between disorders based on medically unexplained symptoms and patients with organic disease.”

If the most recent “Somatic Symptom Disorders” Work Group proposals gain DSM Task Force approval, all medical diseases and disorders, whether “established general medical conditions or disorders” like diabetes or conditions presenting with “somatic symptoms of unclear etiology” will have the potential for a bolt-on diagnosis of “somatic symptom disorder”.

CFS and ME patients may be especially vulnerable to highly subjective and difficult to quantify constructs such as “disproportionate distress and disability”, “catastrophising”, “health-related anxiety”, “[appraising] bodily symptoms as unduly threatening, harmful, or troublesome” with “health concerns [that] may assume a central role in the individual’s life, becoming a feature of his/her identity and dominating interpersonal relationships.”

There may be considerable implications for these highly subjective criteria for the treatments offered to US patients, the provision of social care packages and the payment of medical and disability insurance.

Criteria are set out very briefly in the PowerPoint slides, but the full criteria and key documents need to be scrutinized. The most recent proposals of the DSM-5 “Somatic Symptoms Disorders” Work Group plus two key Disorder Description and Rationale PDF documents can be read on the APA’s DSM-5 Development site here:

http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

Two key Somatic Symptoms Disorders Work Group Draft Proposal documents:

     Revised Justification of Criteria Version 1/31/11

     Revised Disorder Descriptions: Version 1/14/11

The next public review of draft criteria and disorder descriptions has been postponed to August – September, this year, for a period of approximately one month for public review and feedback.

[1] Psychiatric Times Special Report, PSYCHIATRY AND MEDICAL ILLNESS Unexplained Physical Symptoms What’s a Psychiatrist to Do?  Humberto Marin, MD and Javier I. Escobar, MD, 01 August 2008

[Draft criteria superceded by third draft published on May 2, 2012]

Images copyright ME agenda 2011   No unauthorized reproduction.

The next public review of draft criteria and disorder descriptions is scheduled for May/June 2011.

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