Final day: Submissions to third DSM-5 stakeholder review

Page 6  Suzy Chapman J 00  Somatic Symptom Disorder

In his journal article Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? [2] Dr Dimsdale discusses the unreliability of “medically unexplained” as a concept and acknowledges the perils of missed and misdiagnosis:

“…On the face of it, MUS sounds affectively neutral but the term sidesteps the quality of the medical evaluation itself. A number of factors influence the accuracy of diagnoses. Most prominently, one must consider how thorough was the physician’s evaluation of the patient. How adequate was the physician’s knowledge base in synthesizing the information obtained from the history and physical examination? The time pressures in primary care make it difficult to comprehensively evaluate patients and thus contribute to delays and slips in diagnosis. Similarly, physicians can wear blinders or have tunnel vision in evaluating patients.1 Just because a patient has previously had MUS is no guarantee that the patient has yet another MUS. As a result of these factors, the reliability of the diagnosis of MUS is notoriously low…”

For DSM-5 then, the Work Group proposes to deemphasize “medically unexplained” as the central defining feature of this disorder group and instead, shift the focus to the patient’s cognitions – “excessive thoughts, behaviors and feelings” about the seriousness of distressing and persistent somatic symptoms which may or may not accompany diagnosed general medical conditions – and the extent to which “illness preoccupation” is perceived to have come to dominate the patient’s life.

Dr Dimsdale concludes:

“Patients present with an admixture of symptoms, preconceptions, feelings, and illnesses. The task of psychiatric diagnosis is to attend to the patient’s thoughts, feelings, and behaviors that are determining his/her response to symptoms, be they explained or unexplained.”

In proposing to license the application of an additional mental health diagnosis for all illnesses if the clinician considers the patient also meets the criteria for a “bolt-on” diagnosis of SSD, Dr Dimsdale and colleagues appear hell bent on stumbling blindly from the “treacherous foundation” of the “somatoform disorders” into the quicksands of unvalidated constructs and highly subjective, difficult to measure criteria.

Has the Work Group projected for potential increase in law suits against clinicians and APA members for missed diagnoses, misdiagnoses, misapplication of inappropriate treatment regimes and iatrogenic disease that may result from incautious and inept application of its proposed criteria?

  • It is a considerable concern that no clinicians from medical specialities beyond psychiatry and psychosomatics and no general practitioners were invited to sit on the Work Group to input into considerations for the clinical and medico-legal implications of the group’s proposals.

As an advocate, I have received disturbing accounts over the years of patients diagnosed with poorly understood chronic illnesses who have met with contempt and dismissal when presenting in A & E departments following accidents or medical emergencies, or sent home with symptoms univestigated. Broken ribs, initially dismissed as “catastrophising,” where the patient has had to plead for X-rays to be carried out.

Severe, disabling back pain, initially dismissed as “catastrophising” and for which CBT had been prescribed but where eventual scans identified insult to the spinal chord putting the patient at risk of paralysis had surgery not been carried out.

As the patient herself wrote, If someone is very ill and in pain is it not normal to feel distressed? How much distress is too much? Who decides what the right amount of distress for any given situation is? What does ‘disproportionate’ mean in such a situation?”

What barriers to appropriate care and investigation might patients encounter when presenting for primary, specialist or emergency assessment with an additional diagnosis of “SSD” on their medical records?

Dr Dimsdale concedes his committee has struggled from the outset with these B type criteria but feels its proposals are “a step in the right direction.”

Patients deserve better than this; science demands rigor.

In the absence of a substantial body of independent evidence for the SSD construct as a reliable, valid and safe alternative, I urge the Work Group not to proceed with its proposals for the reorganization of the “Somatoform Disorders” categories in favour of the status quo, or to dispense altogether with this section of DSM. There can be no justification for replacing one set of dysfunctional, unreliable and unsafe categories with another.

References

1] Justification of CriteriaSomatic Symptoms, May 4, 2011 for second DSM-5 stakeholder review.
2] Dimsdale JE. Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? Psychiatr Clin N Am 34 (2011) 511–513 doi:10.1016/j.psc.2011.05.003

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