Psychiatric creep – Erasing the interface between psychiatry and medicine

Psychiatric creep – Erasing the interface between psychiatry and medicine

Post #121 Shortlink:

As reported in an earlier post, the third draft of proposals for changes to DSM-IV categories and criteria is delayed because DSM-5 field trials are running behind schedule.

This third and final draft is now expected to be released for public review and comment, “no later than May 2012”, according to DSM-5 Task Force Vice-chair, Darrel Regier, MD [1].


DSM-5 Somatic Symptom Disorders

One focus of this site has been the proposals of the DSM-5 Somatic Symptom Disorders Work Group

Proposed criteria, as they stood in May, last year, are set out on the DSM-5 Development site here:

There are two key PDF documents which expand on the proposals as currently posted:

         Disorders Description  Key Document One: “Somatic Symptom Disorders”

         Rationale Document  Key Document Two: “Justification of Criteria — Somatic Symptoms”


Erasing the interface between psychiatry and medicine 


I first reported on Co-Cure, over two years ago, in May 2009, that the conceptual framework the Somatic Symptom Disorders Work Group was proposing would:

“…allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome.” [2]

(“Somatic” means “bodily” or “of the body”.)

The most recent version of the Somatic Symptom Disorders Disorders description proposals document states:

“This group of disorders is characterized predominantly by somatic symptoms or concerns that are associated with significant distress and/or dysfunction…Such symptoms may be initiated, exacerbated or maintained by combinations of biological, psychological and social factors.”

“These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis. Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met.”

“The symptoms may or may not be associated with a known medical condition. Symptoms may be specific (such as localized pain) or relatively non-specific (e.g. fatigue). The symptoms sometimes represent normal bodily sensations (e.g., orthostatic dizziness), or discomfort that does not generally signify serious disease.” [3]


Psychiatric creep

While the media has focused on the implications for introducing new disorder categories into the DSM and lowering diagnostic thresholds for existing criteria, there has been little scrutiny of the proposals of the Somatic Symptom Disorders Work Group.

This Work Group has been quietly redefining DSM’s Somatoform Disorders categories with proposals that will have the potential for a “bolt-on” diagnosis of a “somatic symptom disorder” for all medical diseases, whether “established general medical conditions or disorders”, like diabetes or angina, or conditions presenting with “somatic symptoms of unclear etiology.”

These radical proposals for rebranding the Somatoform Disorders categories as Somatic Symptom Disorders and combining a number of existing, little-used categories (somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder) under a proposed portmanteau term, Complex Somatic Symptom Disorder (CSSD), and the more recently proposed, Simple Somatic Symptom Disorder (SSSD), which requires symptom duration of as little as one month, have the potential for bringing many thousands more patients under a mental health banner.

Complex Somatic Symptom Disorder (CSSD) criteria are here: 

Simple Somatic Symptom Disorder (SSSD) criteria are here:

These proposals have the potential for expanding markets for psychiatric services, antidepressants and behavioural therapies, like CBT, for the “modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors”  for all patients with somatic symptoms, if the clinician decides that the patient’s response (or in the case of a child, a parent’s response) to bodily symptoms and concerns about their health are “excessive”, or the perception of their level of disability “disproportionate”, or their coping styles “maladaptive.”

Under the guise of “eliminating stigma” and eradicating “terminology [that] enforces a dualism between psychiatric and medical conditions” by “de-emphasizing the concept of ‘medically unexplained'”, the American Psychiatric Association appears hell bent on colonising the entire medical field by licensing the potential application of a mental health diagnosis to all medical diseases and disorders.

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