Patient submissions to third and final DSM-5 stakeholder review

Page 5 US patient 1 to J 00 SSD and J 02 Conversion Disorder (FNSD)

The major weakness of all somatoform disorder definitions has been the attribution of medically unexplained symptoms to psychiatric factors by default, without any burden or means of proof, which is inherently unscientific. The proposed change to the new criteria for conversion disorder removes even the slightest necessity of evidence for psychiatric morbidity, leaving an entirely negative psychiatric definition. How can the absence of a known biomedical pathology be taken as positive evidence of psychopathology, especially when the mechanism for conversion is itself purely hypothetical?

The fact remains that no one has provided sufficient empirical evidence that any ‘conversion’ or ‘somatization’ mechanism even exists. A re-examination of the basic validity and specificity of these somatoform disorder diagnostic constructs is therefore long overdue. Reducing the specificity of these somatoform disorder criteria is the last thing the DSM-5 task force should be doing; either these diagnoses and their precedents should be abandoned altogether until there is sufficient scientific evidence to support such constructs or, at least, the DSM-IV criteria for somatization disorder should be conserved in the DSM-5 while a far more thorough, independent appraisal of the validity and utility of the proposed CD, SSD constructs, as well as of the extant USD construct, takes place.

It is important to consider that the implementation of these new criteria for both SSD and conversion disorder could significantly hinder new disease discovery, or proper surveillance and diagnosis of emerging disease or rare diseases. The SSD criteria are so vague that they could capture any medically unknown disease of sufficient severity; the new conversion disorder criteria could do the same for such diseases with neurological symptoms. Similarly, cases of any disease that is not well understood, not well known to most clinicians, or difficult to diagnose could potentially wind up in either of these dustbin categories, and their labeling as ‘somatoform’ would discourage further investigation in such cases. Thus the decreased specificity of the proposed SSD and conversion disorder criteria will inevitably lead to overdiagnosis and misdiagnosis that could have far reaching effects.

I find it troubling that the larger community of non-psychiatrist clinicians and researchers have not had a tangible role in the development of the DSM’s diagnoses. Such input would be especially relevant for somatoform disease, in which psychiatric and physical illness are hypothesized to overlap. A collaboration with biomedically-oriented clinicians and researchers would no doubt offer broader perspectives on the confusing and contentious issue of somatoform disorders and the design of any proposed diagnoses.

I therefore suggest the DSM-5 task force seek a much broader consensus on the issue of somatoform disorder diagnoses, and abandon plans for adding any diagnosis that has highly questionable clinical validity and/or is based on unvalidated hypotheses. The newly proposed criteria for both SSD and conversion disorder should be abandoned for these reasons.

The magnitude of damage that can be done to patients through inappropriate psychiatric diagnoses, psychiatric overdiagnosis, and the resulting biomedical underdiagnosis cannot be overstated. Simply put, people’s lives and relationships have been made much more difficult or even destroyed, and their much-needed health benefits/disability pay cut or stopped entirely, due to misdiagnosis with somatoform disorders. In the continued application of these diagnoses and their further development, I urge the DSM-5 Task Force to consider that the precept “Do No Harm” may be violated as much by inherently flawed diagnostic entities as it may be by flawed practitioners.

References

1: Johnson SK, DeLuca J, and Natelson BH. “Assessing Somatization Disorder in Chronic Fatigue Syndrome”. Psychosomatic Medicine 1996; 58:50-57

2: Carruthers et al “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols” J Chronic Fatigue Syndrome 2003, 11(1): 7-115
http://name-us.org/DefintionsPages/DefinitionsArticles/ConsensusDocumentFull.pdf

3: Carruthers et al “Myalgic Encephalomyelitis: International Consensus Criteria” J Intern Med 2011; 270(4): 327–338

4: Mayou R et al. “Somatization Disorders: Time for a New Approach in DSM-5” Am J Psychiatry 2005; 162: 847-855

5: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revision, Washington, DC, American Psychiatric Association, 2000.

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