Psychiatric creep – Erasing the interface between psychiatry and medicine

The so-called “Functional somatic syndromes” would be particularly vulnerable to the application of a Complex Somatic Symptom Disorder (CSSD) label.

CFS and ME patients who already have a diagnosis, or are awaiting diagnosis, would be especially vulnerable to the highly subjective criteria and very difficult to measure constructs such as “disproportionate distress and disability”, “catastrophizing”, “health-related anxiety” and “[appraising their] bodily symptoms as unduly threatening, harmful, or troublesome” this Work Group is currently proposing.

Other patient groups that are bundled under the “Functional somatic syndromes” and “medically unexplained” umbrellas, like Fibromyalgia, IBS, Chemical Injury (CI), Chemical Sensitivity (CS), chronic Lyme disease and Gulf War illness would also be potentially vulnerable to being caught by these proposals.

These proposals could potentially result in misdiagnosis with a mental health disorder, misapplication of an additional “bolt-on” diagnosis of a mental health disorder to a general medical condition, missed diagnoses through failure to investigate new or worsening symptoms or iatrogenic disease from psychotropic drugs.

Families caring for children and young people with any long-term illness may be at increased risk of wrongful accusation of “over-involvement” or “excessive” concern for a child’s symptomatology or of encouraging maintenance of “sick role behaviour” in an ill child or adolescent.

Application of vague and highly subjective criteria may have considerable implications for the diagnoses assigned to patients, provision of social care, payment of employment, medical and disability insurance, and the length of time for which insurers are prepared to pay out.

The misapplication of a diagnosis of Complex Somatic Symptom Disorder (CSSD), may limit the types of treatment, medical investigations and testing that clinicians are prepared to consider and for which insurers are prepared to fund.

I urge all clinicians and end-users of the DSM, social workers and lawyers to scrutinise these proposals.

 

International implications

This is not a US centric issue. The DSM is used to a varying extent in other countries in clinical settings and DSM criteria are currently used more often for research purposes than ICD-10; the next edition of the DSM will shape international research, influence literature in the fields of psychiatry and psychosomatics and inform perceptions of patients’ medical needs throughout the world.

By the time the third draft is published, it is questionable how much impact submissions from end-users and stakeholders – clinicians, allied mental health professionals, patients, advocates and patient advocacy groups might have at this late stage in the drafting process.

But when the next draft is released in April or May, please use this final opportunity to tell the APA why the Somatic Symptom Disorders Work Group needs to urgently reconsider its proposals.

 

Harmonization with ICD-10-CM and ICD-11

There has been a degree of concordance between the Somatoform Disorders section of DSM-IV and the corresponding section of ICD-10 Chapter: V Mental and behavioural disorders. (Note: ICD-10-CM Somatoform Disorders categories are little changed from ICD-10, from which ICD-10-CM has been developed.)

Table 1: Current DSM-IV Codes and Categories for Somatoform Disorders and ICD-10 Equivalents [3]

For the forthcoming editions of DSM-5 and ICD-11, APA and WHO have committed as far as possible, “To facilitate the achievement of the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioural disorders and DSM-V disorders and their diagnostic criteria.” with the objective that “The WHO and APA should make all attempts to ensure that in their core versions, the category names, glossary descriptions and criteria are identical for ICD and DSM.”

The Somatic Symptom Disorders Work Group has taken the existing DSM-IV categories, dumped them in a bucket, stirred them up with a stick, tipped them out and assigned new labels to them. WHO has strict taxonomic rules for ICD codings and classifications. It is difficult to see how congruency between the corresponding sections of the two classification systems could be achieved under current proposals.

The framework the Work Group proposes, if approved, would effect a major restructuring of the “Somatoform Disorders” section. Could ICD Revision accommodate these radical proposals to combine a number of existing categories under a new rubric by creating a new category “CSSD” within ICD’s more rigid taxonomic structure and conventions – even if WHO classification experts, ICD Revision Steering Group and the ICD-11 Topic Advisory Group for Mental and behavioural disorders were to consider these proposed categories and criteria valid constructs?

The Work Group’s Rationale/Validation document fails to address the issue of whether concordance between these sections of the two classification systems might be viable under current Work Group proposals. Nor does it consider the implications for incongruency for the mapping across of categories and codes from DSM-5 to ICD-10-CM* equivalents on the operational usefulness of this section of the forthcoming DSM-5.

(*Since October 1, 2011, ICD-10-CM has been subject to a partial code freeze in preparation for implementation on October 1, 2013. Between October 1, 2011 and October 1, 2014 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.)

 

References

Proposed criteria are set out on the DSM-5 Development site here: http://tinyurl.com/Somatic-Symptom-Disorders

The CSSD criteria are here: http://tinyurl.com/DSM-5-CSSD

[1] DSM-5 Task Force Ponders Round 2 of Public Feedback: Deborah Brauser for Medscape Medical News
August 31, 2011 [Registration required to view this Medscape article.]

[2] “The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report” was published in the June 2009 issue of the Journal of Psychosomatic Research. At the time of publication, J Psychosoma Res was co-edited by DSM-5 Work Group members, Prof Francis Creed and Dr James Levenson. Full free text: http://www.jpsychores.com/article/S0022-3999(09)00088-9/fulltext

[3]  Mayou R, Kirmayer LJ, Simon G, Kroenke K, Sharpe M: Somatoform disorders: time for a new approach in DSM-VAm J Psychiat. 2005;162:847–855.

[4] Two key PDF documents: “Disorders Descriptions” and “Rationale”, which expand on the Work Group’s proposals as currently posted on the DSM-5 Development site:

              Disorders Description  Key Document One: “Somatic Symptom Disorders”

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

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