Patient submissions to third and final DSM-5 stakeholder review

Page 3 US patient 1 to J 00 SSD and J 02 Conversion Disorder (FNSD)

Those ‘non-CFS symptoms’ found with high prevalence in this study included dizziness (76% of CFS subjects), shortness of breath and tachycardia (55%), nausea, and ‘loss of feeling’. Significantly, these symptoms are frequently reported by both CFS and myalgic encephalomyelitis (ME) patients, and in fact were incorporated into older ME definitions, the later Canadian Consensus ME/CFS definition, and the recently published International Consensus definition of ME 2,3. Both CFS and ME patients have frequently been found to have associated dysautonomias – including Neurally Mediated hypotension and POTS – which themselves would explain complaints of dizziness, tachycardia, and shortness of breath. Tachycardia is also a feature of deconditioned or metabolically-challenged bodies under physical strain, as is likely to be the case for people with a chronic physical illness.

As for loss of feeling and nausea, various forms of neuropathy, parathesia, and gastrointestinal dysfunction are also commonly associated with ME and CFS. Thus, without taking the clinical experience of biomedical specialists in CFS and ME into consideration, the average clinician relying upon somatoform disease criteria or similar psychiatric instruments would be prone to misdiagnosing CFS and ME patients with SD. This could potentially be the case with any disease with which the diagnosing clinician is relatively unfamiliar.

The results for CFS in this study demonstrate the excessively subjective nature of an archetypal somatoform disorder diagnosis, and its vulnerability to clinician bias. This study’s results for MS patients also underlined the importance of a higher symptom number cutoff, and therefore higher specificity; MS patients received an SD diagnosis at least 15% of the time in subsets 1a and 2a (which reduced the cutoff from 13 to either 6 or 4) but were undiagnosed in all other sets.

Unfortunately, rather than truly address the fundamental problems with the DSM-III-R SD criteria revealed by Johnson et al and other studies, the DSM-IV added a far less specific, far more subjective diagnosis called Undifferentiated Somatoform Disorder (USD). And now, the DSM-5 Task Force proposes to replace both of these diagnoses with a new construct, Somatic Symptoms Disorder (SSD), which is even less specific than USD and which is utterly dependent on subjective clinical interpretation.

Flawed as they may themselves be, the DSM-IV criteria for somatization disorder did at least have greater operational specificity than both the USD and SSD criteria, by virtue of their requirements for a certain pattern and number of symptoms. Unfortunately the DSM-IV SD and USD criteria both allow the clinician to determine, without any guidance, whether a given symptom is explicable by a known general medical condition. That’s a problem because it makes the huge assumption that each doctor has, or has access to, ultimate knowledge of every known disease. The DSM-IV SD and USD criteria also allows for a somatization disorder diagnosis whenever the patient’s response to symptoms is deemed ‘excessive’ or ‘unwarranted’. There is no operationalization for this criterion, no burden of proof on the clinician – his/her subjective opinion, as superficial as it may be, at any given time, is considered to be enough.

The proposed SSD criteria remove whatever specificity might be said to exist in the DSM-IV somatization disorder criteria, lower the necessary number of symptoms to just one (as in the USD criteria), and concentrate on the worst aspect of the DSM-IV SD and USD criteria – the (previously optional) ‘excessive complaint’ criterion – expand it, and makes it even more subjective, and therefore even more likely to be misapplied. Further, the SSD criteria contain no specification – however optional – that symptoms must be medically unexplained, which allows SSD to be applied as a ‘bolt-on’ diagnosis to any disease or condition.

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