ICD-11 Beta draft: Rationale for Proposal for Deletion of proposed new category: Bodily distress disorder

Post #328 Shortlink: http://wp.me/pKrrB-4dc

ICD-11 Beta draft Proposal Mechanism:

https://tinyurl.com/ICD11BDDsubmission

(Registration with the Beta draft required in order to view proposals)

  ICD-11 Bodily distress disorder submission

Proposal submitted by Suzy Chapman, Dx Revision Watch, via ICD-11 Beta draft Proposal Mechanism

Submitted: March 1, 2017

The author has no affiliations or conflicts of interest to declare.

Rationale for Proposal for Deletion of the Entity: Bodily distress disorder

1: The acronym “BDD” is already in use to indicate Body Dysmorphic Disorder [1].

2: With limited field studies, there is currently no substantial body of evidence for the validity, reliability, utility, prevalence, safety and acceptability of the S3DWG’s proposed disorder construct. However, the focus of this rationale is the proposed nomenclature.

The Somatic Distress and Dissociative Disorders Working Group (S3DWG) proposes to name its construct, “bodily distress disorder (BDD)” – a term that is already used by researchers and in the field interchangeably with the disorder term, “bodily distress syndrome (BDS).”

“Bodily distress syndrome” is a conceptually divergent disorder construct: differently defined and characterized, with different criteria that are already operationalized in Denmark and beyond, in research and clinical settings, and which potentially include a different patient set to that described in the S3DWG’s proposal [2].

As defined for the ICD-11 core version, the S3DWG’s “bodily distress disorder” construct has stronger conceptual and characterization alignment with DSM-5 “somatic symptom disorder (SSD)” than with Fink et al. (2010) “bodily distress syndrome” [3][4].

It is noted that “Somatic symptom disorder” is listed under Synonyms for the BDD entry in the ICD-11 Beta draft.

The defining feature of both the S3DWG’s “bodily distress disorder” and DSM-5 “somatic symptom disorder” is the removal of the distinction between “medically explained” and “medically unexplained” somatic complaints. Rather than define the disorder on the basis of the absence of a known medical cause, instead, specific psychological features are required in order to fulfill the criteria.

The S3DWG’s BDD is characterized by “the presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms which may be manifest by repeated contact with health care providers.”

“Excessive attention is not alleviated by appropriate clinical examination and investigations and appropriate reassurance.”

“If a medical condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression.”

“Bodily symptoms and associated distress are persistent, being present on most days for at least several months and are associated with significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

The S3DWG’s “bodily distress disorder” may involve a single unspecified somatic symptom or multiple unspecified symptoms that may vary over time, in association with the disorder’s other defining features.

For DSM-5 “somatic symptom disorder,” the centrality of medically unexplained symptoms in order to meet the criteria is similarly de-emphasized and replaced by psychological responses to distressing, persistent symptoms: “excessive thoughts, behaviours and feelings” or “excessive preoccupation” with the bodily symptom or associated health concerns [5].

As with BDD, for SSD, the symptoms may or may not be associated with another medical condition. Some patients with general medical  diagnoses, such as cancer, cardiovascular disease or diabetes, or patients diagnosed with the so-called “functional somatic syndromes” may qualify for a diagnosis of SSD if they are perceived as experiencing disproportionate and excessive thoughts and feelings or using maladaptive coping strategies in response to their illness, despite the reassurance of their clinicians [6].

As with the S3DWG’s defining of BDD, for SSD, there is no requirement for a specific number of complaints from among specified symptom groups to meet the criteria: so no symptoms counts or symptom clusters from body systems required for either.

To meet the SSD criteria: at least one symptom of at least six months duration and at least one of three psychological criteria are required: disproportionate thoughts about the seriousness of the symptom(s); or a high level of health anxiety; or devoting excessive time and energy to symptoms or health concerns; and for the symptoms to be significantly distressing or disruptive to daily life.

Though they differ somewhat in the characterization of their severity specifiers, the S3DWG’s defining of BDD and DSM-5 SSD may be considered essentially similar in conceptualization: no distinction between “medically explained” and “medically unexplained”; a much simplified criteria set to those defining the somatoform disorders, based on “excessive” or “disproportionate” psychological responses to persistent distressing symptoms, and with significant impairment or disruption to functioning.

Whereas, for the Fink et al. (2010) “bodily distress syndrome (BDS),” psychological or behavioural characteristics are not part of the criteria: symptom patterns or clusters from organ/body systems (cardiopulmonary; gastrointestinal; musculoskeletal or general symptoms) are central [2]. The diagnosis is exclusively made on the basis of the somatic symptoms, their complexity and duration, with moderate  to severe impairment of daily life. There is a “Modest: single organ” type and a “Severe: multi-organ” type.

The Fink et al. (2010) BDS construct is considered by its authors to have the ability to capture the somatoform disorders, neurasthenia, “functional symptoms” and the so-called “functional somatic syndromes” under a single, unifying disorder construct which subsumes CFS, ME, fibromyalgia and IBS (which are discretely classified within other chapters of ICD-10), noncardiac chest pain, chronic pain disorder, MCS and some others [7][8][9].

(The various so-called specialty “functional somatic syndromes” are considered by the authors to be an artifact of medical specialization and manifestations of a similar, underlying disorder with a common, hypothesized aetiology.)

Contrast this with the S3DWG’s BDD construct, which makes no assumptions about aetiology and does not exclude symptoms associated with general medical conditions; whereas, for Fink et al. BDS, “If the symptoms are better explained by another disease, they cannot be labelled BDS.”

That DSM-5 SSD and Fink et al. (2010) BDS are differently conceptualized, with different criteria sets, potentially capturing different patient populations has been acknowledged by SSD work group chair, Joel E Dimsdale, and by Fink, Henningsen and Creed [10][11]. In the literature, however, one observes frequent instances where the term “bodily distress disorder” has been used when what is actually being discussed within the paper or editorial is the Fink et al. (2010) “bodily distress syndrome (BDS)” disorder construct.

For example, “bodily distress disorder” is used interchangeably with “bodily distress syndrome” in the editorial (Creed et al. 2010): Is there a better term than “medically unexplained symptoms”? [1].

In this (Rief and Isaac 2014) editorial: The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? the authors are using the term, “bodily distress disorder” while clearly discussing the Fink et al. (2010) BDS  construct [12].

The S3DWG’s proposed term is seen, here, as “Bodily distress disorder (Fink and Schroder 2010)” in Slide #3 of the symposium presentation: An introduction to “medically unexplained” persistent physical symptoms. (Professor Trudie Chalder, Department of Psychological Medicine, King’s Health Partners, 2014) [13].

This recent paper: Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders (Schumacher et al. 2017) compares prognostic validity of DSM-5 “somatic symptom disorder (SSD)” with “bodily distress disorder (BDD)” and “polysymptomatic distress disorder (PSDD)” and discusses their potential as alternatives to SSD for the replacement of the somatoform disorders for the forthcoming ICD-11 [14].

The authors state, “the current draft of the WHO group is based on the BDD proposal.” But the authors  have confirmed that for their study, they had operationalized “Bodily distress disorder based on Fink et al. 2007” [15].

In the (Fink et al. 2007) paper: Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients, the authors conclude: “We identified a general, distinct, bodily distress syndrome or disorder that seems to encompass the various functional syndromes advanced by different medical specialties as well as somatization disorder and related diagnoses of the psychiatric classification.”

There are other examples in the literature and in the field. But these suffice to demonstrate that the term, “bodily distress disorder” is already used synonymously with disorder term “bodily distress syndrome (BDS)” and that researchers/clinicians, including Fink et al., do not differentiate between the two.

If researchers/clinicians do not differentiate between “bodily distress syndrome” and “bodily distress disorder” (and in some cases, one observes the conflations, “bodily distress syndrome or disorder” and “bodily distress syndrome/disorder”), has the S3DWG considered the difficulties and implications for maintaining the discrete identity of its proposed disorder, once ICD-11 is in the hands of its end users – clinicians, allied health professionals and coders; or considered the implications for patients and the particular vulnerability of those diagnosed with one of the so-called, “functional somatic syndromes”; or the implications for data reporting and analysis?

The S3DWG presented its emerging proposals for subsuming most of the ICD-10 somatoform disorder categories between F45.0 – F45.9, and F48.0 Neurasthenia, under a new single category which it proposes to call “bodily distress disorder (BDD)” in 2012 [3] and again in 2016 [4].

Thus far, the S3DWG has published no rationale for its recommendation to repurpose a disorder term already strongly associated with the Fink et al. (2010) disorder construct.

Neither has the group discussed nor acknowledged within its papers the implications for confusion and conflation between its own SSD- like “BDD” construct and the Fink et al. “bodily distress syndrome (BDS).”

Nor has the group’s output discussed the potential difficulties and implications for maintaining construct integrity within and beyond  ICD-11.

There is no justification for introducing a new disorder category into ICD-11 that has greater conceptual alignment with the DSM-5 SSD construct but is proposed to be assigned a disorder name that is closely associated with a divergent (and operationalized)  construct/criteria set, that is already in use in research and clinical settings.

This is unsafe and unsound classificatory practice.

This proposed disorder name should be rejected by the Project Lead for the revision of the Mental or behavioural disorders chapter and by the Joint Task Force that is overseeing the finalization of ICD-11  MMS.

If the S3DWG is unprepared or unwilling to reconsider and recommend an alternative disorder name then I submit that the current proposal to replace the somatoform disorders with a single “bodily distress disorder” category should be abandoned.

ICD-11 should proceed with the ICD-10 status quo, or retire or deprecate the somatoform disorder categories for the next edition.

It is perhaps germane that in 2010, three years prior to the finalization of DSM-5, Creed et al. had advanced: “Somatic symptom disorder is not a term that is likely to be embraced enthusiastically by doctors or patients; it has an uncertain core concept, dubious wide acceptability across cultures and does not promote multidisciplinary treatment. In our discussion, the terms which fit most closely the criteria we have set out above were the following: bodily distress (or stress) syndrome/ disorder, psychosomatic or psychophysical disorder, functional (somatic) syndrome or disorder.” [1]

The authors conclude that “bodily distress disorder” best fitted their “Criteria to judge the value of alternative terms for ‘medically unexplained symptoms.'”

It would appear that the term “bodily distress disorder” can mean anything anyone chooses it to mean – which might be admissible for Humpty Dumpty but unsound classificatory practice for ICD-11 [16].

References:

1 Creed F, Guthrie E, Fink P, Henningsen P, Rief W, Sharpe M, White P. Is there a better term than “medically unexplained symptoms”? J Psychosom Res. 2010 Jan;68(1):5-8. doi:10.1016/j.jpsychores.2009.09.004. [PMID: 20004295]

2 Fink P, Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res. 2010 May;68(5):415-26. [PMID: 20403500]

3 Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. doi: 10.3109/09540261.2012.741063. [PMID: 23244611]

4 Gureje O, Reed GM. Bodily distress disorder in ICD-11: problems and prospects. World Psychiatry. 2016 Oct;15(3):291-292. doi: 10.1002/wps.20353. [PMID: 27717252]

5 American Psychiatric Association. (2013). Somatic Symptom and Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

6 Frances A, Chapman S. DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. Aust N Z J Psychiatry. 2013 May;47(5):483-4. [PMID: 23653063]

7 Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS. Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Fam Pract. 2013 Feb;30(1):76-87. doi: 10.1093/fampra/cms037. Epub 2012 Jul 28. [PMID: 22843638]

8 Ivbijaro G, Goldberg D. Bodily distress syndrome (BDS): the evolution from medically unexplained symptoms (MUS). Ment Health Fam Med. 2013 Jun;10(2):63-4. [PMID: 24427171]

9 Goldberg DP, Reed GM, Robles R, Bobes J, Iglesias C, Fortes S, de Jesus Mari J, Lam TP, Minhas F, Razzaque B et al. Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO’s revised classification of mental disorders in primary care settings. J Psychosom Res. 2016 Dec;91:48-54. doi:10.1016/j.jpsychores.2016.10.002. Epub 2016 Oct 4. [PMID: 27894462]

10 Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, Francis Creed, Peter Henningsen, Per Fink (Eds), Cambridge University Press, 2011.

11 Frances Creed and Per Fink. Presentations, Research Clinic for Functional Disorders Symposium, Aarhus University Hospital, May 15, 2014.

12 Rief W, Isaac M. The future of somatoform disorders: somatic symptom disorder, bodily distress disorder or functional syndromes? Curr Opin Psychiatry September 2014 – Volume 27 – Issue 5 – p315–319. [PMID: 25023885]

13 Chalder, T. An introduction to “medically unexplained” persistent physical symptoms. Presentation, Department of Psychological Medicine, King’s Health Partners, 2014. [Accessed 27 February 2017]

14 Schumacher S, Rief W, Klaus K, Brähler E, Mewes R. Medium- and long-term prognostic validity of competing classification proposals for the former somatoform disorders. Psychol Med. 2017 Feb 9:1-14. doi: 10.1017/S0033291717000149. [PMID: 28179046]

15 Fink P, Toft T, Hansen MS, Ornbol E, Olesen F. Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients. Psychosom Med. 2007 Jan;69(1):30-9. [PMID: 17244846]

16 Carroll L. Alice’s Adventures in Wonderland. 1885. Macmillan.

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Submission: Proposal: Add Somatic symptom disorder as inclusion term to ICD-10-CM

Post #309 Shortlink: http://wp.me/pKrrB-3WD

You have until Friday in which to submit comments on any of the numerous diagnosis proposals presented at the March ICD-10-CM Coordination and Maintenance Committee meeting.

Comments should be sent to NCHS, preferably by email, by June 20th deadline: nchsicd9CM@cdc.gov

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The next public meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee is scheduled for September 23–24, 2014. If you are planning to attend the meeting in person you will need to register online by September 12. Registration opens on August 15.

New proposals for the September 23–24, 2014 meeting must be received by July 18.

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September 2013 meeting Diagnosis Agenda

The fall meeting of the ICD-9-CM/PCS Coordination and Maintenance Committee took place on September 18–19.

The Diagnosis Agenda had included the proposals to add the new DSM-5 disorder terms: Somatic symptom disorder and Illness anxiety disorder to the ICD-10-CM Tabular List and the Alphabetical Index.

Note that the proposal was to add the terms as Inclusion Terms under existing ICD-10-CM Chapter 5 codes, not to create unique new codes for these two terms, or to replace or subsume any existing categories:

ICD10CM 4

Source: Page 45, Diagnosis Agenda (Topic Packet), September 18–19, 2013 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting

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March 2014 meeting Diagnosis Agenda

The spring C & M Committee meeting took place on March 19–20, 2014. I was unable to attend either meeting as I live in the UK, and it is not feasible for me to participate in these public meetings via phone link.

The March Diagnosis Agenda included reiteration of the September proposal to add Somatic symptom disorder to the ICD-10-CM Alphabetical Index, coded to F45.1. (But did not include a resubmission to add to the Tabular List.) The reason for its reiteration in the March Agenda is unclear.

When the March Agenda requests for additions and modifications to the Tabular List were reached, CDC’s Beth Fisher had remarked that some of the proposals for additions to the Tabular List may have been proposed at the September 2013 meeting (though no explanation was given for why some of these September proposals were being duplicated in the March Agenda).

Evidently some Index proposals from the September meeting were also duplicated in the March Agenda, including SSD, but not Illness anxiety disorder.

There were no comments or queries from the floor in relation to proposals for SSD. There were no queries about whether NCHS decisions had already been reached on the requests for additions and modifications submitted via the September meeting.

It remains unclear whether the duplications in the March Agenda were due to administrative oversight, were being included for procedural reasons, or were being re-presented in response to NCHS committee decisions made following the September meeting, to which APA, but not the public at large, might be party to. (The outcome of both the September and March proposals may not be evident until 2015, when the next Addendum is posted.)

March Agenda proposal: Add Somatic symptom disorder to the Index as “– somatic symptom F45.1” under “Disorders”:

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March14 ICD-10-CM Cand M SSD to Index

Source: Diagnosis Agenda (Topic Packet) Page 89, March 19-20, 2014 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting; Screenshot Videocast Three

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F45.1 (SSD) and F45.21 (Illness anxiety disorder) are the ICD-10-CM codes to which these two new APA disorders are already cross-walked in the DSM-5:

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SSDcrosswalk

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If NCHS rubber stamps the addition of Somatic Symptom Disorder to the ICD-10-CM it could leverage future proposals (either by NCHS/CMS or by external requestors) for the replacement of some or all of the existing Somatoform disorders categories with this new, single SSD diagnostic construct, in order to bring ICD-10-CM in line with DSM-5.

There are implications for ICD-11, too. Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. adaptation of ICD-10 may make it easier for the ICD-11 Revision Steering Group to justify proposals to replace the existing ICD-10 Somatoform disorders categories with a single, new ICD construct incorporating SSD-like characteristics, to facilitate harmonization between ICD-11 and DSM-5 disorder terms and diagnostic criteria.

Comments by June 20th deadline, preferably by email, to: nchsicd9CM@cdc.gov

Below is my own submission to NCHS in PDF

Click link for PDF document   NCHS Submission Chapman June 14

and as text:


To: NCHS  nchsicd9CM@cdc.gov

Re: Comment on proposals, March 19-20, 2014 meeting of ICD-10-CM Coordination and Maintenance Committee.

Diagnosis Agenda Page 89: Under “Proposed Index Modifications”: Add Somatic symptom disorder to ICD-10-CM Alphabetical Index (F45.1)

Proposal requestor: Unspecified

Comment submitted by Suzy Chapman DipAD, [Address redacted]

Date submitted: June 15, 2014

I write in objection to the proposed addition of Somatic symptom disorder to the ICD-10-CM Alphabetical Index for consideration for implementation on October 1, 2015 [or on and after October 1, 2016 after the partial code freeze has ended, as applicable].

This March 19-20, 2014 meeting proposal duplicates the request at the September 18-19, 2013 meeting for the addition of Somatic symptom disorder to the ICD-10-CM Index (and to the Tabular List) as an Inclusion Term to existing code, F45.1 Undifferentiated somatoform disorder.

Somatic symptom disorder is a new disorder conceptualization created by the American Psychiatric Association (APA) for DSM-5.

For DSM-5, the Somatoform Disorders have been dismantled. Four DSM-IV categories: somatization disorder [300.81], some presentations of hypochondriasis [300.7], pain disorder, and undifferentiated somatoform disorder [300.82] are eliminated and replaced with a single new diagnosis, Somatic symptom disorder (SSD), cross-walked in DSM-5 to ICD-9 300.82 (ICD-10-CM F45.1).

The Somatic symptom disorder construct de-emphasizes “medically unexplained” as the central defining feature of this disorder group. Instead, the focus shifts away from somatic symptoms to emotional, cognitive and behavioral disturbances and “maladaptive” responses to symptoms: high levels of health anxiety; disproportionate and persistent concerns about the medical seriousness of the symptom(s); or an excessive amount of time and energy devoted to symptoms and health concerns.

Symptoms may or may not be associated with another medical condition: SSD allows for the application of a mental disorder diagnosis in patients with “established general medical conditions or disorders” like diabetes, heart disease and cancer or presenting with “somatic symptoms of unclear etiology” if the clinician considers the patient otherwise meets the new criteria.

To meet the requirements for DSM-IV’s Somatization disorder, a rigorous criteria set needed to be fulfilled: a history of many medically unexplained symptoms before the age of thirty, resulting in treatment sought or psychosocial impairment. And a high diagnostic threshold: a total of eight or more medically unexplained symptoms from four, specified symptom groups, with at least four pain, two gastrointestinal, one psychosexual and one pseudoneurological symptom.

In DSM-5, the requirement for eight symptoms has been dropped to just one or more persistent, non specific, distressing somatic symptoms and the clinician’s perception of “excessive” or “maladaptive” response to the symptom or symptoms.

• These changes for DSM-5 represent a radical restructuring of the DSM-IV Somatoform disorders framework and introduce a new construct for which much remains to be determined.

On Day Two of the September 18-19, 2013 ICD-9-CM Coordination and Maintenance Committee meeting, Dr Darrel Regier had presented and discussed rationales, coding proposals and timings for six new DSM-5 disorders that APA has proposed for insertion into ICD-10-CM. But the Diagnosis Agenda proposals to add the new DSM-5 Somatic symptom disorder and Illness anxiety disorder category terms as inclusion terms to ICD-10-CM did not form part of Dr Regier’s presentation.

As it was unspecified within the Diagnosis Agenda and during the meeting presentations, it is unclear whether these two proposals are being requested by APA, by NCHS/CMS, or by other parties or individuals.

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• My first concern is that no description of Somatic symptom disorder, no rationale for why this ICD-10-CM modification is needed (including clinical relevancy) and no supporting clinical and literature references for the validity of Somatic symptom disorder as a new disorder were published in the Diagnosis Agenda for either the September or March meeting.

At the public meeting, no presentation had been made on behalf of APA, or by representatives of NCHS or CMS, or by anyone else for the specific Agenda proposal to add Somatic symptom disorder as an inclusion term under an existing ICD-10-CM Somatoform disorders code and there was no discussion of this proposal during the course of the meeting [1][2].

There is an expectation that the committees overseeing the development and revision of the draft for ICD-10-CM will give due consideration to the applicability, clinical utility, safety and reliability of any proposal for the inclusion of a new disorder construct before granting approval for its addition to the Tabular List and Index, and that the comments and objections received during the public response period will also be considered. The lack of rationales and references for supportive evidence provided by the requestors hinders public participation in the response process.

• The absence from the Diagnosis Agendas and meeting presentations of rationales, clinical relevancy and supporting clinical and literature references to enable proper public scrutiny, consideration and informed responses to this proposal should disqualify Somatic symptom disorder from consideration for implementation once the partial code freeze has lifted.

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The burden of proof before introducing any new diagnosis into a classification system is that it has a favourable risk to benefit ratio. This new diagnostic construct created by APA and introduced into DSM-5 merits the same level of scrutiny and risk to benefit evaluation as would be expected to be applied to any proposed new disorder/disease that is under consideration for inclusion in any chapter of ICD, whether this is for the updating of the ICD-10-CM draft, updating of WHO’s ICD-10, updating of clinical modifications of ICD-10, or drafting of ICD-11.

A number of papers have noted the paucity of rigorous evidence for the validity, reliability, acceptability, safety and utility of the application of the Somatic symptom disorder construct in adults and children across diverse clinical settings and by a spectrum of health and allied professionals. There is no significant body of published research on the epidemiology, clinical characteristics or treatment of the Somatic symptom disorder construct [3][4][5].

In a paper published in the Journal of Psychosomatic Research, September 2013, the DSM-5 Somatic symptom disorder Work Group concedes the lack of clinical evidence for its new construct and acknowledges the “small amount of validity data concerning SSD” and “that much remains to be determined” about the utility and reliability of the specific SSD criteria and its thresholds when applied in busy, general clinical practice, and there are “vital questions that must be answered” as they go forward [6].

• As an under researched, poorly validated disorder construct, Somatic symptom disorder does not meet NCHS/CMS criteria for new diseases/new technology procedures, and any minor revisions to correct reported errors in these classification and should be rejected for consideration for implementation during a partial code freeze and also rejected for consideration for implementation on or after October 1, 2015 [October 1, 2016].

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Concerns for the looseness of the Somatic symptom disorder definition and the ease with which these new criteria can be met have been discussed in a number of published papers and commentaries [7][8][9][10].

The over-inclusiveness of the SSD diagnosis is borne out by the results of the DSM-5 field trial study reported by Joel E Dimsdale, MD, chair of the Somatic symptom disorder Work Group, at the 2012 annual meeting of the American Psychiatric Association.

15% of the ‘diagnosed illness’ study group, comprising patients with cancer or coronary disease, were caught by SSD and would meet the criteria for application of an additional mental disorder diagnosis.

26% of the ‘functional somatic’ study group, comprising patients with irritable bowel syndrome or chronic widespread pain, met the SSD criteria.

SSD has a high false positive rate – capturing 7% of the ‘healthy’ field trial control group.

It is disturbing that the SSD Work Group (which had included no primary care physicians or pediatricians) appears not to have undertaken any field trials into the safety of application of the SSD criteria in children and adolescents.

NCHS/CMS provides no references for data for the application of SSD in children within the Diagnosis Agenda, although the DSM-5 text clearly indicates APA’s intention that SSD is a diagnosis that may also be applied to children with persistent, distressing somatic symptoms.

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Potential implications for the application of a diagnosis of SSD:

I am not persuaded that the new SSD diagnosis can be safely applied outside the optimal conditions of field trials, in settings where practitioners may not necessarily have adequate time for, or instruction in administration of diagnostic assessment tools, and where decisions to code or not to code may hang on the arbitrary and subjective perceptions of a wide range of end-users who may lack clinical training in the application of mental disorder criteria.

Misapplication of highly subjective and loose, easily met criteria, especially in busy primary care practice, may result in inappropriate diagnoses of mental disorder and inappropriate medical decision making, with considerable implications for patients [11].

A recent study (Plouvier et al, 2014) found more frequent presentation with functional somatic symptoms and multiple prodromal symptoms in the two year period prior to diagnosis with Parkinson’s disease than controls [12].

Incautious application or a pre-existing diagnosis of SSD in the patient’s notes may blunt clinician alertness and receptivity to emerging prodromal symptomotology of serious disease.

Patients with chronic, multiple bodily symptoms due to rare diseases, difficult to diagnose conditions, or multi system diseases like Behçet’s disease, for which it can take several years to arrive at a diagnosis, may be especially vulnerable to missed diagnosis or to misdiagnosis with a mental disorder, impeding access to testing, investigations, timely diagnosis and early intervention (and may result in increased claims against practitioners for medical negligence).

With the elimination of the requirement that symptoms be “medically unexplained” and inclusion of the presence of a co-occurring physical health condition, a mental disorder diagnosis of SSD can be applied as a “bolt-on” to any chronic medical diagnosis: to patients with diabetes, angina, cancer, MS, cardiovascular disease, ME and CFS, IBS, chronic widespread pain (aka fibromyalgia), chronic pain conditions or persistent symptoms of unclear etiology.

Patients with Chronic fatigue syndrome (CFS), “almost a poster child for medically unexplained symptoms as a diagnosis,” according to the SSD Work Group chair, or with chronic Lyme disease, Gulf War illness, chemical injury and chemical sensitivity; women with potential symptoms of gynecological disease, like ovarian cancer – already often late-diagnosed because persistent symptoms had been initially dismissed as IBS or a menopausal-related bladder complaint; or women with endometriosis or interstitial cystitis may be particularly vulnerable to misapplication or misdiagnosis with a mental health disorder under SSD criteria.

(There is also a Brief somatic symptom disorder in DSM-5, cross-walked to ICD-9 F45.8, that can be applied where duration of symptoms is less than 6 months. Just one somatic symptom and one “disproportionate” psychobehavioral response to that symptom, for less than 6 months chronicity, now ticks the box for a mental health diagnosis.)

There has been considerable opposition to the introduction of this new, poorly tested construct into the DSM-5 amongst patients, carers, advocates, consumer organizations, mental health practitioners and clinicians and considerable concern for the implications for diverse patient populations that the Somatic Symptom Disorder category will provide a “dustbin diagnosis” for the so-called “functional somatic syndromes,” for those living with chronic pain and for patients with persistent, but as yet undiagnosed, symptoms of disease.

• NCHS/CMS has published no independent field trial data and provided no rationales or clinical and literature references to inform public responses.

Given the lack of published evidence for the validity and safety of SSD, there is insufficient basis for the approval of SSD for inclusion within ICD-10-CM and it would be scientifically unsafe, premature and against the public interest to include this new diagnostic construct within ICD.

The proposal for the addition of Somatic symptom disorder to the ICD-10-CM as an inclusion term to the Index and Tabular List should be rejected. There should be no implementation in October 2016 as an inclusion term to F45.1, or to any other existing code, or with a unique code created.

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Appendix:

Incautious, inept application of criteria resulting in a “bolt-on” psychiatric diagnosis of Somatic symptom disorder has far-reaching implications for diverse patient populations:

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

Patients with cancer and life threatening diseases may be reluctant to report new symptoms that might be early indicators of recurrence, metastasis or secondary disease for fear of attracting a diagnosis of SSD or being labelled as “catastrophizers.”

Application of an additional diagnosis of SSD may have implications for the types of medical investigations, tests and interventions that clinicians are prepared to consider and for which insurers are prepared to fund.

Application of an additional diagnosis of SSD may impact payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out.

 An SSD diagnosis may negatively influence the perceptions of agencies involved with assessment and provision of social care packages, disability adaptations, workplace accommodations, provision of education arrangements tailored to the needs of children with chronic illness, and the perceptions of medical staff during hospital and accident and emergency admission, and prejudice future employment options.

Patients prescribed psychotropic drugs for perceived unreasonable levels of “illness worry” or “excessive preoccupation with symptoms” may be placed at risk of iatrogenic disease or subjected to inappropriate and costly behavioural therapies.

Multi-system diseases like Multiple Sclerosis, Behçet’s disease or Systemic lupus 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 to being labelled with a mental disorder.

The burden of the DSM-5 changes to Somatoform disorders will fall particularly heavily upon women who are more likely to be casually dismissed when presenting with physical symptoms and more likely to be prescribed inappropriate antidepressants and anti-anxiety medications for them.

Somatic symptom disorder allows for the application of a diagnosis of SSD in children and where a parent is perceived as being excessively concerned about a child’s symptoms.

The diagnostic term “Somatic Symptom Disorder” is already being applied to children despite the lack of a body of evidence for the reliability, safety and validity of the DSM-5 SSD criteria [13].

I am deeply concerned that NCHS/CMS is considering inclusion of a new diagnostic term within ICD when no studies have been carried out into the safety of its application in children and adolescents.

Families caring for children and young people with any chronic disease or condition may be placed at increased risk of wrongful accusation of “over-involvement” with their child’s symptomatology.

Where a parent is perceived as responsible for, or encouraging maintenance of “sick role behavior” or “secondary gains” in a child, this can trigger social services investigation, or court intervention for the forced removal of a sick child out of the home environment and into foster care or in-patient rehabilitation, or placement of the child on the “at risk register.”

This is already happening to families in the U.S., UK and Europe with a child or young adult with chronic illness, notably with Chronic fatigue syndrome or ME. It may happen more frequently with a diagnosis of SSD or of chronic childhood illness + SSD.

Where there are disputes between the family and clinicians over an assigned diagnosis or where there is disagreement between clinicians over the etiology of a child’s symptoms, an earlier or concurrent diagnosis of SSD may prejudice the family’s rights and the rights of the child or young person to determine what treatments are administered, where and by whom; or may be used to override or attempt to override the right to consent to treatments, or as a means of limiting parental access to the child and parental involvement in a treatment plan.

A diagnosis of SSD may also impact on a child’s access to suitable educational arrangements, including part-time school attendance, rest periods, reduced curriculum, home tutoring, examination concessions, provision of an amanuensis etc. and access to disability aids and adaptations, or to unhindered use of existing aids, such as wheelchairs.

Again, there is insufficient basis for the approval of SSD for inclusion within ICD-10-CM for application in children or adults. It is scientifically unsafe, premature and against the public interest to include this poorly tested diagnostic construct within ICD.

Thank you for your consideration.

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References:

1.Diagnosis Agenda,September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee.

2.Summary of Diagnosis Presentations, September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee.

3. DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions and Justification of Criteria – Somatic Symptoms, published May 2011, for second DSM-5 stakeholder review.

4. Robert L. Woolfolk and Lesley A. Allen (2012). Cognitive Behavioral Therapy for Somatoform Disorders, Standard and Innovative Strategies in Cognitive Behavior Therapy, Dr. Irismar Reis De Oliveira (Ed.), ISBN: 978-953-51-0312-7

5. Ghanizadeh A, Firoozabadi A. A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V. Psychiatr Danub. 2012 Dec;24(4):353-8.

6. Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, Lee S, Irwin MR, Levenson J. Somatic Symptom Disorder: An important change in DSM. J Psychosom Res. 2013 Sep;75(3):223-8. Epub 2013 Jul 25.

7. Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013 Mar 18;346:f1580. doi: 10.1136/bmj.f1580.

8. Frances A. DSM-5 Somatic Symptom Disorder. J Nerv Ment Dis. 2013 Jun;201(6):530-1. doi: 10.1097/NMD.0b013e318294827c.

9. Frances A, Chapman S. DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. Aust N Z J Psychiatry. 2013 May;47(5):483-4. doi:10.1177/0004867413484525.

10. Wolfe F, Walitt BT, Katz RS, Häuser W. Symptoms, the nature of fibromyalgia, and diagnostic and statistical manual 5 (DSM-5) defined mental illness in patients with rheumatoid arthritis and fibromyalgia. PLoS One. 2014 Feb 14;9(2):e88740. doi: 10.1371/journal.pone.0088740. eCollection 2014.

11. Dimsdale JE. Medically unexplained symptoms: a treacherous foundation for somatoform disorders? Psychiatr Clin North Am 2011;34:511-3.

12. Plouvier AO, Hameleers RJ, van den Heuvel EA, Bor HH, Olde Hartman TC, Bloem BR, van Weel C, Lagro-Janssen AL2. Prodromal symptoms and early detection of Parkinson’s disease in general practice: a nested case-control study. Fam Pract. 2014 May 28. pii: cmu025. [Epub ahead of print]

13. Commonwealth of Massachusetts Juvenile Court Department, Court document, Honourable Joseph Johnston, March 25, 2014, Re: Care and Protection of Justina Pelletier: http://cbsboston.files.wordpress.com/2014/03/scan.pdf

Interest:

Carer/advocate for adult with long-term medical condition. Owner of website Dx Revision Watch, Monitoring the revision of DSM-5 and ICD-11. Co-author, journal papers and commentaries on the SSD construct (with Professor Allen Frances).

 

CMS posts ICD-10-CM Release for 2015; confirms Partial Code Freeze extension; reminder, SSD proposals

Post #306 Shortlink: http://wp.me/pKrrB-3SJ

This report updates on the revised implementation date for ICD-10-CM, the revised Partial Code Freeze timeline, the ICD-10-CM Release for 2015 files, and a reminder of the deadline for objections to the insertion of DSM-5’s Somatic symptom disorder into ICD-10-CM.

[For reminder of deadline for objections to proposed insertion of Somatic symptom disorder into ICD-10-CM, skip to red subheading.]

On April 1, 2014, Bill H.R. 4302, known as the PAM Act (Protecting Access to Medicare Act), was signed into law by President Obama.

As a result of a quietly inserted clause piggybacking on this Bill, implementation of ICD-10-CM was delayed by a further year. Centers for Medicare & Medicaid Services (CMS) has confirmed that the effective implementation date for ICD-10-CM is now October 1, 2015.

Until that time, the codes in ICD-10-CM (the U.S. specific adaptation of the WHO’s ICD-10) are not valid for any purpose or use.

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Partial Code Freeze

CMS has announced that the partial code freeze on updates to the ICD-9-CM and ICD-10-CM diagnosis and procedure codes will continue until October 1, 2015.

Between October 1, 2011 and October 1, 2016 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. Regular (at least annual) updates to ICD-10-CM/PCS will resume on October 1, 2016.

The Partial Code Freeze document has been updated to reflect the revised Timeline and can be accessed here in PDF format Partial Code Freeze for ICD-9-CM and ICD-10

or text, below:

Partial Code Freeze for ICD-9-CM and ICD-10

The ICD-10 Coordination and Maintenance Committee (formerly the ICD-9-CM Coordination and Maintenance Committee) implemented a partial freeze of the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior to the implementation of ICD-10 which would end one year after the implementation of ICD-10. There was considerable support for this partial freeze. On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. When published, links will be provided to this interim final rule at http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html

The partial freeze will be implemented as follows:

• The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on October 1, 2011.

• On October 1, 2012, October 1, 2013, and October 1, 2014 there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L. 108-173.

• On October 1, 2015, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173. There will be no updates to ICD-9-CM, as it will no longer be used for reporting.

• On October 1, 2016 (one year after implementation of ICD-10), regular updates to ICD-10 will begin.

The ICD-10 Coordination and Maintenance Committee will continue to meet twice a year during the partial freeze. At these meetings, the public will be asked to comment on whether or not requests for new diagnosis or procedure codes should be created based on the criteria of the need to capture a new technology or disease. Any code requests that do not meet the criteria will be evaluated for implementation within ICD-10 on and after October 1, 2016 once the partial freeze has ended.

CDC has not yet updated its webpages to reflect the ICD-10-CM implementation delay or the revised Partial Code Freeze timeline.

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SSD and ICD-10-CM/PCS Coordination and Maintenance Committee proposals

At the September 2013 and March 2014 Coordination and Maintenance Committee meetings, the American Psychiatric Association (APA) submitted numerous requests for addenda changes for new index entries and tabular inclusion terms for evaluation for implementation on October 1, 2015.

It is unclear whether requests for modifications submitted by APA and other requestors via these September and March meetings will be rolled forward for evaluation for implementation on and after the revised date of October 1, 2016 or whether these proposals will now need to be resubmitted at future C & M Committee meetings. (The next public meeting takes place September 23–24, 2014.)

I have approached NCHS for clarification.

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If the proposals from these two meetings do require resubmitting, this would provide another opportunity to comment on the proposal to add the DSM-5’s new disorder term, Somatic symptom disorder, to the ICD-10-CM.

See earlier post: Update on proposal to add DSM-5′s Somatic symptom disorder to ICD-10-CM

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At the public Coordination and Maintenance Committee meeting on September 18–19, 2013, a proposal had been submitted to add Somatic symptom disorder (SSD) as an inclusion term to existing ICD-10-CM code F45.1 Undifferentiated somatoform disorder in the Tabular List Addendum (this also included addition to the Index).

Note: Proposal is not to create a unique code for SSD or to replace any of the existing ICD-10-CM somatoform disorders with SSD, but to add SSD as an inclusion term under an existing ICD-10-CM code, F45.1.

September 18–19, 2013 meeting Agenda, Page 45: PDF Agenda

ICD10CM 4

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The proposal to add somatic symptom disorder to the Index (under Disorder), was resubmitted at the public meeting on March 19–20, (reason unclear but a number of proposals for modifications to both the Tabular List and the Index from the September 2013 meeting were also duplicated at the March 2014 meeting).

March 19–20, 2014 meeting Agenda, Page 89: PDF Agenda

March14 ICD-10-CM Cand M SSD to Index

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Any decisions made on the considerable number of proposals requested at last year’s September meeting are yet to be posted and possibly won’t be evident until the relevant Addendum is released.

In the DSM-5, Somatic symptom disorder is already cross-walked to ICD-9 code 300.82 (ICD-10-CM F45.1):

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DSM-5 (Page 311)

SSDcrosswalk

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Given that APA worked with CDC on the cross-walk between the new DSM-5 disorder terms and ICD-9/ICD-10-CM equivalent codes, NCHS’s Director will likely rubber stamp the APA’s proposals for insertion of SSD and a number of other new DSM-5 categories.

Nevertheless, I shall be putting in another objection before the June 20 deadline and I hope all stakeholders with concerns will strongly oppose the incorporation of this controversial new disorder construct into ICD-10-CM.

The deadline for comments on proposals requested at the March meeting is June 20th.

Send comments, by email, to NCHS to nchsicd9CM@cdc.gov

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Not a small thing

Between 2010 and 2012, the SSD Work Group attracted considerable opposition across three stakeholder reviews to its radical proposals for a replacement for the somatoform disorders.

In late 2012 and early 2013, we saw a good deal of “outrage” in comments to articles by Allen Frances and myself here and here at Psychology Today and here in the BMJ, in response to the cavalier decision by the Task Force to barrel through with the SSD Work Group’s poorly validated disorder construct.

But I see little evidence of sustained opposition from U.S. professionals and patients over the September and March NCHS/CMS update and revision meeting proposals to insinuate SSD into ICD-10-CM.

At the moment, the proposal is for inserting SSD as an inclusion term under an existing category – not to create a unique code for SSD and not to replace the existing framework with SSD. At the September meeting, CDC’s Donna Pickett said:

“…And just to complete the package, there are other Tabular List proposals that appear on Page 45 and 46 that we would also invite your comments on. And again, with some of the terminology changes that Dr Regier has described the intent here is to make sure that if those terms are being used, that they do have a home somewhere within ICD-10-CM to facilitate people looking these up. So we invite comments…”

Sounds almost cosy. But if NCHS does rubber stamp the addition of Somatic symptom disorder to ICD-10-CM, it could leverage future replacement of the existing Somatoform disorders categories with this new, single diagnostic construct, bringing ICD-10-CM’s framework in line with DSM-5.

There are implications for ICD-11, too.

Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. modification of ICD-10 may make it easier for ICD-11 Revision Steering Group to justify approving proposals to replace the existing ICD-10 Somatoform disorders categories with a single, new disorder construct that would mirror SSD’s defining characteristics – its positive psychobehavioural features, its simplified criteria, its de-emphasis on “medically unexplained” and facilitate harmonization between ICD-11 and DSM-5 disorder terms.

Christopher Chute, Mayo, chairs the ICD-11 Revision Steering Group. Chute has suggested that following implementation, ICD-10-CM might be brought gradually in line with ICD-11 through a series of annual updates, for smoother transition to ICD-11-CM.

Inserting the SSD term into ICD-10-CM paves the way for disorder construct congruency between DSM-5, ICD-10-CM, ICD-11, and eventually, the ICD-11-CM modification.

Send comments, by email, by June 20, to NCHS at nchsicd9CM@cdc.gov

 

CMS posts files for ICD-10-CM Release for 2015

On May 15, CMS posted the ICD-10 Procedure Coding System (ICD-10-PCS) files for 2015, download files here:

On May 19, CMS posted the ICD-10-CM and GEMs files for 2015:

These files (some of which are large ZIP files) include:

2015 Code Descriptions in Tabular Order

2015 Code Tables and Index – Updated 5/22/14 (includes Tabular List, and Index in PDF format)

2015 ICD-10-CM Duplicate Code Numbers

2015 Addendum

2015 General Equivalence Mappings (GEMs) – Diagnosis Codes and Guide

2015 Reimbursement Mappings – Diagnosis Codes and Guide

According to the Addendum, “There were no changes to the 2014 ICD-10-CM, therefore there are no 2015 ICD-10-CM Addenda.”

These ICD-10-CM Release for 2015 files are not yet available on the CDC site but when they are posted, they should be accessible from this page: http://www.cdc.gov/nchs/icd/icd10cm.htm

 

Further reading

Justina Pelletier: The Case Continues Phil Hickey, April 4, 2014
Objection to proposal to insert DSM-5′s Somatic symptom disorder into ICD-10-CM Suzy Chapman, Public submission, ICD-9-CM/PCS Coordination and Maintenance Committee Meeting September 18-19, 2013
Somatic Chapter Drops Centrality Of Unexplained Medical Symptoms Psychiatric News, Mark Moran, March 1, 2013
Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care David J Kupfer, MD, Chair, DSM-5 Task Force, defends the SSD construct, Huffington Post, February 8, 2013
The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill Allen Frances, MD, BMJ 2013;346:f1580 BMJ Press Release PDF for full text
Somatic Symptom Disorder could capture millions more under mental health diagnosis Suzy Chapman, May 26, 2012
Mislabeling Medical Illness As Mental Disorder Allen Frances, MD, Psychology Today, DSM 5 in Distress, December 8, 2012
Why Did DSM 5 Botch Somatic Symptom Disorder? Allen Frances, MD, Psychology Today, Saving Normal, February 6, 2013
New Psych Disorder Could Mislabel Sick as Mentally Ill Susan Donaldson James, ABC News, February 27, 2013

Global creep of DSM-5’s Somatic symptom disorder

Post #303 Shortlink: http://wp.me/pKrrB-3Qq

Update at April 14, 2014:

Written response (April 10, 2014) from Independent Hospital Pricing Authority (IHPA) to request for clarification regarding the term ‘Somatic symptom disorder’ and Australia’s clinical modification of ICD-10, ICD-10-AM:

PDF: IHPA response re SSD and ICD-10-AM


 

As previously posted:

In the previous posting Update on proposal to add DSM-5′s Somatic symptom disorder to ICD-10-CM I reported that NCHS is preparing to rubber stamp proposals to insert Somatic symptom disorder into the U.S.’s forthcoming clinical modification of ICD-10.

Comments/objections to Diagnosis Agenda proposals submitted at the March meeting need to be sent by email to NCHS at nchsicd9CM@cdc.gov by June 20th.

1] According to this Australian legislative document:

http://www.comlaw.gov.au/Details/F2014L00304

Australian Government, Statement of Principles concerning somatic symptom disorder No. 24 of 2014

for the purposes of the Veterans’ Entitlements Act 1986 and Military Rehabilitation and Compensation Act 2004

“Somatic symptom disorder attracts ICD-10-AM code F45.1.”

For the purposes of the Statement of Principles:

“ICD-10-AM code” means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Eighth Edition, effective date of 1 July 2013, copyrighted by the Independent Hospital Pricing Authority, and having ISBN 978-1-74128-213-9;”

The Australian ICD-10-CM, Eighth Edition, July 2013 is not in the public domain. As I do not have access to a copy, I have contacted the relevant body for clarifications.

I have asked whether Somatic symptom disorder has been added to the Eighth Edition of ICD-10-AM as an Inclusion term to F45.1 Undifferentiated somatoform disorder in the Tabular List and Alphabetical Index.

Or, whether this legislative document relies on the ICD cross-walk codes as published in the DSM-5 in May 2013 for the cross-walk between DSM-5 disorders and the disorders in the U.S.’s ICD-9-CM and forthcoming ICD-10-CM.

Or, whether the legislative document relies on a cross-walk between DSM-5 disorders and ICD-10-AM codes developed specifically in relation to the ICD-10-AM Eighth Edition, July 2013.

I will update this post when I have received clarification.

According to this page: http://nccc.uow.edu.au/icd10am-achi-acs/overview/icd10am/index.html

“[Australia’s] ICD-10-AM has also enjoyed more widespread use, having been assessed, found suitable and adopted by many other countries, including: New Zealand, Ireland, Singapore, Slovenia.”

I am unable to confirm how many countries that have adopted ICD-10-AM have migrated from earlier editions to the July 2013 edition or are preparing to migrate to the most recent edition.

Other clinical modifications (CMs) of ICD-10:

Canada (ICD-10-CA): The most recent edition of ICD-10-CA is the 2009 edition Volume One: Tabular List 2009. Canada is anticipated to adopt a CM of ICD-11 before the U.S. does, but in meantime, an updated edition of ICD-10-CA might be anticipated, especially given the recent extension to the ICD-11 development timeline. Canadians will need to be alert to the potential for addition of SSD as an inclusion term to the next edition of ICD-10-CA.

Germany (ICD-10-GM): There is an ICD-10-GM version for 2014. There is no SSD under F45.x or under any other code, but watch for any updated versions released prior to transition to a CM of ICD-11.

Thailand (ICD-10-TM): There does not appear to be a more recent version of the Thai clinical modification than the online version for 2007, but watch for SSD in any updated versions prior to potential transition to a CM of ICD-11. ICD-10-TM Online version for 2007.

ICD-11 Beta drafting platform:

There is no documentary evidence of a proposal to add SSD, per se, to ICD-11. However, the wording for the Definition for Bodily distress disorder, as it currently stands in the Beta drafting platform, is drawn from the Gureje, Creed 2012 paper on the S3DWG sub working group’s emerging proposals for ICD-11 [1].

The paper described a simplified disorder framework – a construct into which DSM-5′s Somatic Symptom Disorder could be comfortably integrated, thus facilitating harmonization between the respective ICD-11 and DSM-5 disorder construct and criteria replacements for the Somatoform disorders classifications.

As with DSM-5′s SSD, for the emerging proposals for BDD, the focus was not on symptoms counts, or on strict symptom patterns or clusters from one or more body systems, or on whether symptoms were determined as being “medically explained” or “medically unexplained,” but on the perception of disproportionate or maladaptive psychobehavioural responses to, or excessive preoccupation with any troublesome chronic bodily symptom(s). And that in doing away with the “unreliable assumption of its causality” the diagnosis of BDD would not exclude the presence of a co-occurring physical health condition – which is very close to SSD’s defining characteristics.

1. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. http://www.ncbi.nlm.nih.gov/pubmed/23244611 [Abstract. Full text behind paywall]

2] On the Patient.co.uk site, a peer reviewed article on Somatic symptom disorder:

http://www.patient.co.uk/doctor/somatic-symptom-disorder

This article is not a recommendation and it draws heavily on the DSM-IV and current ICD-10 Somatoform disorders framework, criteria and literature. Though it does highlight that DSM-5 has a new, simplified framework and reformulated criteria that rely less on strict patterns of somatic symptoms and more on the degree to which a patient’s thoughts, feelings and behaviours about their symptoms are considered disproportionate or excessive; that for DSM-5, “medically unexplained” is de-emphasized – symptoms may or may not be associated with another medical condition and patients with organic comorbidities such as heart disease, osteoarthritis or cancer, who would have previously been excluded under DSM-IV, can now be included in the diagnosis of SSD.

There is little published research examining the reliability, utility, epidemiology, clinical characteristics or treatment of Somatic symptom disorder as a diagnostic construct and none of the article’s references are for papers specifically using the new Somatic symptom disorder criteria.

3] Somatic symptom disorder in a BMJ Rapid Response:

Rapid Response to: Clinical Review, Fibromyalgia by Anisur Rahman, Martin Underwood, Dawn Carnes [Full text for Clinical Review behind paywall]

http://www.bmj.com/content/348/bmj.g1224/rr/689294

Rapid Response: Fibromyalgia: an unhelpful diagnosis for both patients and doctors [Full text for Rapid Response accessible]

Christopher Bass, consultant in liaison psychiatry, John Radcliffe Hospital , Oxford OX3 9DU

Dr Max Henderson, senior lecturer in Epidemiology and Occupational psychiatry, Inststitute of psychiatry, Kings College London 

According to the authors, fibromyalgia ( coded in ICD-10 under Chapter XXIII Diseases of the musculoskeletal system and connective tissue, at M79.7 ) is more appropriately described in terms of “polysymptomatic distress”; “polysymptomatic distress has been recognised as a somatoform disorder, specifically as a somatic symptom disorder or SSD,” and that since “FM overlaps with other disorders with medically unexplained symptoms such as irritable bowel syndrome and chronic fatigue syndrome” it is more appropriate to treat them with multidisciplinary teams within the same specialised service in the general hospital.

4] This commentary by infectious disease specialist, Judy Stone, MD, at Scientific American blogs, mentions concerns around SSD:

Have Pain? Are You Crazy? Rare Diseases Pt. 2

By Judy Stone | February 18, 2014

“It’s all in your head,” patients with unexplained pain or unexpected symptoms often hear…

5] Halifax Somatic Symptoms Disorder Trial

http://clinicaltrials.gov/show/NCT02076867

ClinicalTrials.gov Identifier: NCT02076867

Sponsor: Capital District Health Authority, Canada

The purpose of this study is to compare the effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP) plus Medical Care As Usual (MCAU) compared to MCAU for Somatic Symptom and Related Disorders (SSRD). Consenting patients presenting to the emergency department with suspected SSRD will be randomly allocated to receive either 8 weekly individual sessions of ISTDP or to an 8-week wait list followed by ISTDP. MCAU including emergency department and/or family doctor consultation is available throughout trial participation. The primary outcome measure is participant self-reported somatic symptoms at week 8.

 

Update on proposal to add DSM-5’s Somatic symptom disorder to ICD-10-CM

Post #302 Shortlink: http://wp.me/pKrrB-3PE

Update at April 5, 2014: Implementation of the U.S.’s forthcoming adaptation of ICD-10, ICD-10-CM, has been kicked further down the road to no earlier than October 1, 2015.

Bill H.R. 4302, known as the PAM Act (Protecting Access to Medicare Act), was signed into law by President Obama on April 1, 2014. This means that the U.S. cannot now transition from ICD-9-CM to ICD-10-CM on October 1, 2014. CMS has yet to issue a full statement, update its webpages and issue guidelines for a new implementation date. No statement has yet been made concerning the impact of this legislation on the timeline for the ICD-10-CM update process during a partial code freeze.

Update at April 5, 2014: The Summary of the March 19–20, 2014 meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee meeting has now been posted

Lots of “outrage” over SSD and DSM-5 but I see little evidence of sustained “outrage” over proposals to add SSD as an Inclusion term to the U.S.’s ICD-10-CM.

If NCHS rubber stamps the addition of Somatic Symptom Disorder to ICD-10-CM it could leverage the future replacement of the existing Somatoform disorders categories with this new, poorly validated single SSD diagnostic construct, bringing ICD-10-CM in line with DSM-5.

There are implications for ICD-11, too.

Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. adaptation of ICD-10 may make it easier for ICD-11 Revision Steering Group to justify proposals to replace the existing ICD-10 Somatoform disorders categories with a single, new ICD construct contrived to incorporate SSD-like characteristics and facilitate harmonization between ICD-11 and DSM-5 disorder terms and diagnostic criteria.

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This post updates on proposals at the March meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee to add DSM-5’s controversial new Somatic symptom disorder as an Inclusion term to ICD-10-CM.

But first, a necessary recap of the September 2013 meeting:

ICD-10-CM/PCS Coordination and Maintenance Committee meetings provide a public forum to discuss proposed changes to the U.S.’s forthcoming ICD-10-CM and ICD-10-PCS, scheduled for implementation on October 1, 2014 to be confirmed.

The public meetings, which are co-chaired by representatives for CMS and NCHS, take place in March and September and are followed by public comment periods.

The fall meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee was held on September 18–19, 2013.

On Day Two of the September meeting, American Psychiatric Association’s Darrel Regier, MD, had proposed six new DSM-5 disorders for inclusion in ICD-10-CM.

On Page 45 and 46 of the Diagnosis Agenda, under Additional Tabular List Inclusion Terms for ICD-10-CM, a number of other changes to specific Chapter 5 F codes had also been proposed. These were introduced en masse, by CDC’s Donna Picket. (Reached on Day Two, at 1:22:21 in from the start of Videocast Four.)

This section of the Diagnosis Agenda included the proposals to add the new DSM-5 disorders: Somatic symptom disorder (proposed to Add as an Inclusion term to F45.1 Undifferentiated somatoform disorder) and Illness anxiety disorder (proposed to Add as Inclusion term to F45.21 Hypochondriasis) to ICD-10-CM’s Chapter 5 codes.

(F45.1 and F45.21 are the ICD-10-CM codes to which these two new APA disorders are already cross-walked in the DSM-5.)

ICD10CM 4

Source: Page 45, Diagnosis Agenda (Topic Packet), September 18–19, 2013 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting

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Videocasts of the entire September 2013 meeting proceedings, Diagnosis Agenda (Topic Packet), Procedural Agenda, Meeting materials etc can be found in Dx Revision Watch Post #277.

Note: there was no proposal at the September 2013 meeting to create a unique code for either Somatic symptom disorder (SSD) or Illness anxiety disorder, for either 2014 or October 1, 2015 implementation, and no proposal that Somatic symptom disorder should replace or subsume any of the existing ICD-10-CM F45.x Somatoform disorders. Note also, these proposals are specific to the forthcoming U.S. clinical modification of ICD-10.

In relation to the section of the Agenda on Pages 45 and 46, CDC’s, Donna Picket, had stated:

1:22:21 in: Diagnosis Agenda: “Additional Tabular List Inclusion Terms for ICD-10-CM”
Donna Pickett (CDC): “…And just to complete the package, there are other Tabular List proposals that appear on Page 45 and 46 that we would also invite your comments on. And again, with some of the terminology changes that Dr Regier has described the intent here is to make sure that if those terms are being used, that they do have a home somewhere within ICD-10-CM to facilitate people looking these up. So we invite comments. We’re showing the Tabular List proposed changes; however, there obviously would be associated Alphabetic Index changes with that which we didn’t show just to keep the package a little bit smaller…”
Source: [Unofficial transcription from Video Four, September 2013 ICD-9-CM C & M Committee meeting.]

There were no questions or comments from the floor or by phone link on any of the proposals listed on Pages 45 and 46 under “Additional Tabular List Inclusion Terms for ICD-10-CM” and no discussion or queries on any of the individual proposals listed under under this section of the Agenda between the meeting co-chairs and APA’s, Dr Regier.

NCHS’s decision on proposals to add Somatic symptom disorder (SSD) and Illness anxiety disorder as Inclusion terms to ICD-10-CM Tabular List Chapter 5, and to also add to the Index, isn’t known and may not be evident until the next ICD-10-CM Addenda is released, later this year, or until the Final Addenda released.

Some of the objections that were submitted last year to the proposal to add Somatic symptom disorder (SSD) as an Inclusion term in ICD-10-CM at the September 2013 meeting are collated on Dx Revision Watch here.

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March 2014 meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee

This meeting took place on March 19–20, 2014. I was unable to attend as I live in the UK.

The ICD-9-CM and ICD-10-CM Timeline and Diagnosis and Procedure Codes Agenda (Topic Packet) can be found here, on the CDC website:

Proposals (Topic Packet) March 19-20, 2014

Procedure Agenda, Meeting Materials and Handouts can be downloaded from Zip files here, on the CMS website:

Meeting Materials March 19-20, 2014

A Summary Report of the Diagnosis part of the meeting is scheduled to be posted on the NCHS website, in June.

A Summary Report of the Procedure part of the meeting is scheduled to be posted on the CMS website, in June.

April 17, 2014: Deadline for receipt of public comments on proposed procedure code revisions discussed at the March 19, 2014 ICD-10 Coordination and Maintenance Committee meeting for implementation on October 1, 2014.

June 20, 2014: Deadline for receipt of public comments on proposed code revisions discussed at the March 19–20 meeting for implementation on October 1, 2015.

ICD-10-CM is currently subject to a partial code freeze. During the freeze, the public will be asked to comment on whether or not a proposal should be approved, and if not, why; and whether requests for new diagnosis or procedure codes should be created based on the criteria of the need to capture a new technology or disease. Any code requests that do not meet the criteria will be evaluated for implementation within ICD-10-CM on and after October 1, 2015 to be confirmed once the partial freeze has lifted.

Comments on the diagnosis proposals presented at the ICD Coordination and Maintenance Committee meeting should be sent, preferably by email, to the following address by June 20th deadline: nchsicd9CM@cdc.gov

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The Two Day proceedings were streamed live and can be watched on YouTube:

Video One: Day One: Morning Session: Procedural Codes: 2014 Mar 19th, FY 2014 ICD-10 Coordination and Maintenance Committee

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Video Two: Day One: Afternoon Session: Procedural Codes: 2014 Mar 19th, FY 2014 ICD-10 Coordination and Maintenance Committee

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Video Three: Day Two: Diagnosis Codes: 2014 Mar 20th, FY 2014 ICD-10 Coordination and Maintenance Committee

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Page 64, Topic Packet: http://www.cdc.gov/nchs/data/icd/Topic_packet_3_19_2014.pdf

[Extract]

Chapter 5 Addenda

The American Psychiatric Association (APA) proposes the following addenda changes to the ICD-10-CM Tabular and Index, specifically to Chapter 5, Mental, Behavioral and Neurodevelopmental disorders (F01-F99).

The APA indicates that these revisions are necessary because DSM-5 contains several new diagnoses, as well as new disorder titles, that do not map well to any existing ICD-10-CM codes.

Because of this, they are proposing numerous new index entries and tabular inclusion terms to ensure that coders can correctly identify the codes to use. The APA proposes that these changes will also ensure that new DSM-5 disorder titles correspond to a valid ICD-10-CM code.

Many of the changes in the proposed addenda relate to the reconceptualization of the substance use disorders from having separate disorder names and codes for substance abuse and dependence. However, extensive scientific evidence was assembled to show that, rather than existing as two separate disorders, these conditions exist on a spectrum that the APA has now conceptualized as ranging from mild to moderate to severe. In order to make the closest approximations with existing ICD-10-CM codes, it is noted that codes for mild substance use disorders correspond to the abuse codes and codes for moderate and severe substance use disorders correspond to dependence codes. The APA may recommend changes in the structure and names of ICD-10-CM substance related disorders, in the future, however at the present time they are only recommending the addition of the new terminology as inclusion terms.

The following addenda are proposed for implementation on October 1, 2015

[…]

1:12:12 in from start of YouTube Three: Chapter 5 Addenda Proposed Tabular Modifications.

1:12:12 Beth Fisher (CMS): Introduces proposals for [Tabular] modifications from APA for Chapter 5. These are all Addenda type changes because [ICD-10-CM is] in code freeze mode, we didn’t have the opportunity to do new codes just yet. Hands podium to Darrel Regier, MD.

1:13:01 Darrel Regier (APA): Mapping DSM-5 to ICD-10-CM codes; Major change to rename Dementias group to Major Neurocognitive Disorders, because including in this group some neurocognitive deficit conditions such as Traumatic brain injury and other neurocognitive disorders that are not inherently some of the neurodegenerative diseases, such as Alzheimer’s, Picks Disease. (Page 64 Diagnosis Agenda)

1:14:02 Darrel Regier (APA): We’ve also introduced [in DSM-5] a Mild neurocognitive disorder that reflects the Mild cognitive impairment, MCI, that is currently in ICD-9, ICD-10…

1:15:06 Darrel Regier (APA): A lot of significant changes to substance abuse disorder area which will require some notes and guidelines…

1:15:27 Darrel Regier (APA): [APA has] a number of new disorders…15 new disorders that are in the DSM-5, but there were 50 disorders that were actually subsumed into a spectrum of conditions that dropped the total number of disorders by something like 28; so you had 50 disorders that collapsed into 22 disorders. Among those, some of the most prominent – Aspergers, Autism, Pervasive developmental disorder NOS, into a single Autism spectrum disorder…assessed on two domains…assessed in terms of level of severity instead of categorical distinctions…

1:17:04 Darrel Regier (APA): Eliminating distinction between abuse and dependence so that on a continuum of Mild, Moderate, Severe…no strict separation between abuse category and dependence…

1:21:00: Question from floor re Alcohol abuse, Alcohol dependence.

1:31:15 Beth Fisher (CDC): Some of these Inclusion terms may have been proposed at September 2013 meeting. (But does not explain the reason for their being resubmitted at the March meeting.)

1:31:34 Beth Fisher (CDC): Begins running through all Addenda Additions.

1:31:42 Beth Fisher (CDC): At F44 Dissociative and conversion disorders, Add Conversion disorder, in parenthesis, functional neurological symptom disorder as Inclusion term.

March 2014 C and M meeting Conversion disorder (FNSD)

Source: ICD-10-CM C & M Committee meeting, March 20, 2014, Screenshot Video Three

Note, there was no proposal under these Proposed Tabular Modifications to Add Somatic symptom disorder as Inclusion term to F45.1 Undifferentiated somatoform disorder to the Tabular List. But the proposal to Add Somatic symptom disorder as an Inclusion term to F45.1 Undifferentiated somatoform disorder to the Tabular List and to the Alphabetical Index had been proposed at the September 2013 meeting.

Also, no proposal to Add Illness anxiety disorder to the Tabular List, but again, this had been proposed at the September 2013 meeting (under F45.21), for both the Tabular List and the Index. (Decisions on all four of these September 2013 meeting proposals are unknown.)

1:34:06 Beth Fisher (CMS): Concludes proposed Addenda Additions to Chapter 5 Tabular List.

1:34:12 Beth Fisher (CMS) Moves onto Proposed Index Modifications from Page 82, Topic Packet.

1:42:36 Beth Fisher (CMS) Page 89: [Under main Index term “Disorder”] And then Somatic symptom disorder to F45.1.

Page 89, Diagnosis Agenda Add Somatic symptom disorder

March14 ICD-10-CM Cand M SSD to Index

Source: ICD-10-CM C & M Committee meeting, March 20, 2014, Screenshot Video Three

(No comments from floor regarding proposal to Add SSD to Index, or queries in respect of outcome of September meeting proposals. It was not feasible for me to participate in this meeting via phone link from UK to query.)

Note, there was no proposal under Proposed Index Modifications to add Illness anxiety disorder to the Index, but this proposal had been included in the September 2013 Topic Packet. Why SSD has been resubmitted for consideration for addition to the Index at the March 2014 meeting is unclear, and as I say, the outcome of proposals for the September meeting for both SSD and IAD to be added to both Tabular List and to Index is unknown.

1:44:25 Beth Fisher (CMS): Concludes proposed Addenda Additions to Chapter 5 Alphabetical Index. Invites comments.

1:44:26: Questions from floor regarding Alcohol; Cannabis; Cocaine use; Implications for legal differences between states for use of cannabis. Question regarding Neurodegeneration due to alcohol.

1:50.02 Beth Fisher (CMS): Other Addenda (Ed: presumably Tab and Index Addenda on pp 91–93 and 93–97) were reached on Day One, as there was time, so not being presenting on Day Two. Invites further comments.

1:50.27 Donna Picket (CDC): Adjourns meeting. Reminds floor (and participants via phone link/videocasts and non attendees), to submit comments on Diagnosis proposals by June 20 deadline.

1:51:07 Question from floor: Process question: if these proposals are all approved, when will they be approved and when will they be effective, because we want to notify our members of what codes to use?

1:51:32: Donna Pickett (CDC): All of these being presented were for consideration for implementation in October 1, 2015. Within 2015, we have a huge body of work that has been accumulating during partial code freeze and we’ve encouraged comments to come in about the timing for making the Final Addenda available. The typical time frame we have used in the past is posting [Addenda] in June and proposals to become effective October 1, of that same year. However, issues have arisen because there is a huge body of work and it was mentioned, yesterday, [during Meeting Day One] that the industry may want to have an Addenda released earlier and we invited comment on that, because of the amount of work that would need to go into incorporating the changes into the relevant systems and programs etc. If we were to stay with the traditional process, the Addenda would be made available in June. Meeting concluded.

Comments on the diagnosis proposals presented at the ICD-10-CM Coordination and Maintenance Committee meeting should be sent, preferably by email, to the following address by June 20th deadline: nchsicd9CM@cdc.gov

New paper by Wolfe et al on reliability and validity of SSD diagnosis in patients with Rheumatoid Arthritis and Fibromyalgia

Post #295 Shortlink: http://wp.me/pKrrB-3LP

This post is an update to Post #284, November 17, 2013, titled:

Correspondence In Press in response to Dimsdale et al paper: Somatic Symptom Disorder: An important change in DSM

In December 2013, Journal of Psychosomatic Research published four letters in response to the Dimsdale el al paper including concerns from Winfried Häuser and Frederick Wolfe for the reliability and validity of DSM-5’s new Somatic symptom disorder:  The somatic symptom disorder in DSM 5 risks mislabelling people with major medical diseases as mentally ill.

A new paper has been published by PLOS One on February 14, 2014:

Symptoms, the Nature of Fibromyalgia, and Diagnostic and Statistical Manual 5 (DSM-5) Defined Mental Illness in Patients with Rheumatoid Arthritis and Fibromyalgia Frederick Wolfe, Brian T. Walitt, Robert S. Katz, Winfried Häuser

The paper is published under Open Access and includes the full SSD criteria in Table S1

The paper’s references include the following commentaries and an article by science writer, Michael Gross:

Frances A, Chapman S (2013) DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. Australian and New Zealand Journal of Psychiatry 47: 483–484. doi: 10.1177/0004867413484525 [PMID 23653063]

Frances A (2013) The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ: British Medical Journal 346. doi: 10.1136/bmj.f1580 [PMID 23511949]

Gross M (2013) Has the manual gone mental? Current biology 23: R295–R298. doi: 10.1016/j.cub.2013.04.009 Full text

Full paper, Tables and Figures in text or PDF format:

Symptoms, the Nature of Fibromyalgia, and Diagnostic and Statistical Manual 5 (DSM-5) Defined Mental Illness in Patients with Rheumatoid Arthritis and Fibromyalgia Frederick Wolfe, Brian T. Walitt, Robert S. Katz, Winfried Häuser

Text version

PDF version

Abstract

Purpose

To describe and evaluate somatic symptoms in patients with rheumatoid arthritis (RA) and fibromyalgia, determine the relation between somatization syndromes and fibromyalgia, and evaluate symptom data in light of the Diagnostic and Statistical Manual-5 (DSM-5) criteria for somatic symptom disorder.

Methods

We administered the Patient Health Questionnaire-15 (PHQ-15), a measure of somatic symptom severity to 6,233 persons with fibromyalgia, RA, and osteoarthritis. PHQ-15 scores of 5, 10, and 15 represent low, medium, and high somatic symptom severity cut-points. A likely somatization syndrome was diagnosed when PHQ-15 score was ≥10. The intensity of fibromyalgia diagnostic symptoms was measured by the polysymptomatic distress (PSD) scale.

Results

26.4% of RA patients and 88.9% with fibromyalgia had PHQ-15 scores ≥10 compared with 9.3% in the general population. With each step-wise increase in PHQ-15 category, more abnormal mental and physical health status scores were observed. RA patients satisfying fibromyalgia criteria increased from 1.2% in the PHQ-15 low category to 88.9% in the high category. The sensitivity and specificity of PHQ-15≥10 for fibromyalgia diagnosis was 80.9% and 80.0% (correctly classified = 80.3%) compared with 84.3% and 93.7% (correctly classified = 91.7%) for the PSD scale. 51.4% of fibromyalgia patients and 14.8% with RA had fatigue, sleep or cognitive problems that were severe, continuous, and life-disturbing; and almost all fibromyalgia patients had severe impairments of function and quality of life.

Conclusions

All patients with fibromyalgia will satisfy the DSM-5 “A” criterion for distressing somatic symptoms, and most would seem to satisfy DSM-5 “B” criterion because symptom impact is life-disturbing or associated with substantial impairment of function and quality of life. But the “B” designation requires special knowledge that symptoms are “disproportionate” or “excessive,” something that is uncertain and controversial. The reliability and validity of DSM-5 criteria in this population is likely to be low.

 

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