Final day: Submissions to third DSM-5 stakeholder review

Page 5 Suzy Chapman J 00  Somatic Symptom Disorder

Implications for a diagnosis of SSD for all patient populations

Incautious, inept application of criteria resulting in a “bolt-on” psychiatric diagnosis of a “Somatic Symptom Disorder” may have far-reaching implications for all patient populations:

Application of highly subjective and difficult to measure criteria could potentially result in misdiagnosis with a mental health disorder, misapplication of an additional diagnosis of a mental health disorder or missed diagnoses through dismissal and failure to investigate new or worsening somatic symptoms.

Application of an additional diagnosis of “Somatic Symptom Disorder” may have implications for the types of medical investigations, tests, treatments and procedures that clinicians are prepared to consider and which insurers are prepared to fund.

Application of an additional diagnosis of “Somatic Symptom Disorder” may impact payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out. It may negatively influence the perceptions of agencies involved with the assessment and provision of social care, disability adaptations and workplace accommodations.

Patients prescribed psychotropic drugs for perceived unreasonable levels of “illness worry” or “excessive preoccupation” with somatic symptoms may be placed at risk of iatrogenic disease.

For multi-system diseases like Multiple Sclerosis, Behçet’s syndrome or Systemic lupus it can take several years before a diagnosis is arrived at. In the meantime, patients with chronic, multiple somatic symptoms who are still waiting for a diagnosis would be vulnerable.

Patients who have already received or are in the process of being assessed for an additional diagnosis of SSD may be reluctant to report new and troublesome symptoms for fear of adding to “symptom counts” or of being labelled as “catastrophisers.”

The B type criteria allow for the application of a diagnosis of “Somatic Symptom Disorder” where a parent is considered excessively concerned with a child’s symptoms [1]. Families caring for children with any chronic illness may be placed at increased risk of wrongful accusation of “over-involvement” with a child’s symptomatology.

Where a parent is perceived as encouraging maintenance of “sick role behaviour” in a child, this may provoke social services investigation or court intervention for removal of a sick child out of the home environment and into foster care or enforced in-patient “rehabilitation.” This is already happening in families with a child or young person with chronic illness, notably with Chronic fatigue syndrome or ME. It may happen more frequently with a diagnosis of a chronic childhood illness + SSD.

Although the Work Group is not proposing to classify Chronic fatigue syndrome, ME, IBS and fibromyalgia, per se, within the “Somatic Symptom Disorders”, patients with CFS – “almost a poster child for medically unexplained symptoms as a diagnosis,” according to Dr Dimsdale’s presentation – or with fibromyalgia, irritable bowel syndrome, chronic Lyme disease, Gulf War illness, chemical injury and chemical sensitivity may be particularly vulnerable to misapplication of or misdiagnosis with a mental health disorder under these SSD criteria.

  • There is considerable concern that this new “Somatic Symptom Disorder” category will provide a “dustbin diagnosis” into which the so-called “functional somatic syndromes” might be shovelled.

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