DSM-5: New category proposal “Simple Somatic Symptom Disorder”

DSM-5: New category proposal “Simple Somatic Symptom Disorder”

Post #57 Shortlink: http://wp.me/pKrrB-TA

On 16 January, I reported that the page for current DSM-5 proposals for the revision of the DSM-IV “Somatoform Disorders” categories and diagnostic criteria had been updated on 14 January, with a new category proposal calledSimple Somatic Symptom Disorder”.

This proposal is in addition to the recommendations of the Somatic Symptom Disorders Work Group, published in February 2010, for grouping a number of existing Somatoform categories under a common rubric “Complex Somatic Symptom Disorder (CSSD)” and does not replace “CSSD”.

For full details see previous Post #56: http://wp.me/pKrrB-St 

Simple Somatic Symptom Disorder

Updated January-14-2011

See Tab: Proposed Revision:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

Simple (or abridged) Somatic Symptom Disorder (e.g. pain)

To meet criteria for Simple Somatic Symptom Disorder, criteria A, B, and C are necessary.

A. One or more highly distressign [sic] and disabling somatic symptoms

B. One of the following symptoms from CSSD (i.e. Disproportionate and persistent concerns about the medical seriousness of one’s symptoms; high level of health-related anxiety; or excessive time and energy devoted to these symptoms or health concerns)

C. Symptom duration is greater than 1 month

For full proposals for “Simple Somatic Symptom Disorder” open the Tabs on this page:

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

 

Key links and documents associated with the proposals of the Somatic Symptom Disorders Work Group:

DSM-5 Development website: Somatoform Disorders
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

Proposal: Complex Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368

Proposal: Simple Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=491

Update @ 7 February 2011

The Justification of Criteria document was revised again by the SSD Work Group on 1/31/11 to incorporate the proposal for SSSD and other revisions and is replaced by:

DRAFT 1/31/11 Justification of Criteria – Somatic Symptoms

        Revised Disorder Descriptions: Version 1/14/11

        Previous revised Justification of Criteria: Version 10/4/10

I shall be monitoring the DSM-5 Development website and if there are any further revisions to either document before the DSM-5 beta is published I will update this site.

According to the APA’s DSM-5 Development Timeline, the second draft is scheduled to be published by the DSM-5 Task Force in May-June, with a public review period of only around a month. The public review and comment period for the first draft, last year, had been around ten weeks.

The following patient organisations have been alerted to these revisions and sent copies of the key documents:

UK patient organisations:

Heather Walker, Action for M.E.
Neil Riley, Chair, Board of Trustees, ME Association
25% ME Group
Invest in ME
Jane Colby, The Young ME Sufferers Trust

US patient organisations and professionals:

Dr Alan Gurwitt, Massachusetts Chronic Fatigue and Immune Dysfunction Syndrome/Myalgic Encephalopathy and Fibromyalgia Association (Mass. CFIDS/ME & FM)
Dr Kenneth Friedman, IACFS/ME
Jennie Spotila, CFIDS Association of America
Dr Lenny Jason

International patient organisations and professionals:

ESME (European Society for ME)
Dr Eleanor Stein, Canada

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Submissions in response to DSM-5 draft criteria from Suzy Chapman

Submissions in response to DSM-5 draft criteria from Suzy Chapman

Post #38 Shortlink: http://wp.me/pKrrB-Gd

Submissions

Patient organisations, professionals and advocates submissions are being collated on this dedicated Dx Revision Watch page: http://wp.me/PKrrB-AQ 

If you would like your submission added please get in touch via the Contact form

In response to: Somatic Symptom Disorders > Complex Somatic Symptom Disorder

Although the Diagnostic and Statistical Manual of Mental Disorders does not have quite the relevance for UK and some European patient populations, since ICD Chapter V is used in some countries in preference to the DSM, diagnostic criteria in the forthcoming edition will shape the international research and literature landscape and influence not only how disorders are defined for international research purposes but how patients and their needs are perceived by those responsible for their medical treatment and social care. It is hoped then, that the views of those submitting responses to the preliminary draft proposals from outside the USA will be afforded due consideration.

I submit the following comments and concerns with regard to:

Somatic Symptom Disorders > Complex Somatic Symptom Disorder

I welcome the decision of the Task Force to extend review of the preliminary draft revisions to the lay public as well as to APA members, clinicians, health professionals, researchers, administrators and other end users and for the Task Force’s recognition that patients, their carers, families and advocates and the patient organisations that represent their interests are crucial stakeholders in any consultation process. Their input merits particular consideration given the absence of patient representation within the individual Work Groups.

Since 2007, when the initial Work Groups were first assembled, the infrequency of reports and their brevity and lack of detail has made it difficult for those outside the field and the lay public to monitor the progress of the various Work Groups. Some Work Groups, for example, this group for Somatic Symptom Disorders, have published reports and editorials in subscription journals which are not readily available to those outside the field and without access to journal papers.

It would have been helpful if the publication of the free access Editorial: Dimsdale J, Creed F: The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report on behalf of the Somatic Symptom Disorders Work Group in the June ’09 edition of J Psychosom Res, 66 (2009) 473–476, which discussed and expanded on the proposals in your brief April ’09 progress update, could have been noted on the Somatic Symptom Disorders Work Group Progress Report page for wider dissemination.

It might be considered a purely tokenistic gesture by the Task Force to extend involvement in the DSM-5 development process to the lay public if they are unable to inform themselves around the deliberations of the groups charged with revision because they are largely excluded from the literature, symposia, conferences and workshops where discussions around proposals are taking place. They therefore rely on more detailed reports, and the paucity and sketchiness of Work Group reports to date has disappointed.

I acknowledge that the Task Force has had to balance opening up the draft proposals review exercise to a wide range of stakeholders against conducting a more restricted consultation process in which responses are collated, published and responded to. It is, however, disconcerting for both professionals and the lay public to tender responses into which considerable effort may have been invested if there is no feedback on how those comments, concerns and suggestions have been received by the respective Work Groups and in the knowledge that their submissions will not be visible for scrutiny by other stakeholders, since there appear to be no plans for aggregating and publishing summaries of the key areas of concern for each set of Work Group proposals.

Given that major changes in diagnostic nomenclature are being proposed for the revision of DSM-IV “Somatoform Disorders” categories, does the Work Group plan to publish an update on any reconsiderations and modifications the group intends to adopt before finalising proposals in readiness for field trials and in the interests of transparency, will it also note key areas of concern for which the Work Group does not intend to make accommodations?

Complex Somatic Symptom Disorder

There is considerable concern amongst international patient organisations and advocates for the implications of the “Somatic Symptom Disorders” Work Group proposal for combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders under a common rubric – “Somatic Symptom Disorders”, and for the creation of a new classification, “Complex Somatic Symptom Disorder” (CSSD).

Professionals in the field, interest groups and the media have been voicing concerns for the last couple of years that proposals for the broadening of criteria for some DSM categories would bring many more patients under a mental health diagnosis.

But if these major revisions to the “Somatoform Disorders” categories were to be approved there would be medical, social and economic implications to the detriment of all patient populations and especially those bundled by many of your colleagues within the field of liaison psychiatry and psychosomatics under the so-called “Functional Somatic Syndromes” (FSS) and “Medically Unexplained Syndromes” (MUS) umbrellas.

The Somatic Symptom Disorders Work Group’s proposal to redefine “Somatoform Disorders” would legitimise the potential for the application of an additional diagnosis of “Somatic Symptom Disorder” to all medical diseases and disorders, whether diagnosed general medical disorders, psychiatric disorders or so-called “unexplained medical symptoms and syndromes”; dual-diagnosing general medical conditions under the guise of “eliminating mind-body dualism.”

There are significant concerns for the implications for patients with Chronic fatigue syndrome, ME, Fibromyalgia, IBS, chemical injury, chemical sensitivity, chronic Lyme disease and GWS.

In the June ’09 Journal of Psychosomatic Research Editorial “The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report”, which expanded on the group’s brief April report, Chair, Joel Dimsdale, MD, and fellow Work Group member, Francis Creed, MD, reported that by doing away with the “controversial concept of medically unexplained”, the proposed classification might diminish “the dichotomy, inherent in the ‘Somatoform’ section of DSM-IV, between disorders based on medically unexplained symptoms and patients with organic disease.”

The conceptual framework the group were proposing, at that point:

“…will allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome.”

Javier Escobar, MD, Director of the University of Medicine and Dentistry of New Jersey (UMDNJ) – Robert Wood Johnson Medical School (RWJMS) Medically Unexplained Physical Symptoms (MUPS) Research Center, which has been supported with over $4M in funding by the National Institute of Mental Health (NIMH) is a DSM-5 Task Force member. It is understood that Dr Escobar serves as a Task Force liaison to the Somatic Symptom Disorders Work Group and is said to work closely with your group [1].

In the August ’08, Psychiatric Times Special Report “Unexplained Physical Symptoms: What’s a Psychiatrist to Do?” [2] co-authors, Escobar and Marin, wrote:

“…Perhaps as a corollary of turf issues, general medicine and medical specialties started carving these syndromes with their own tools. The resulting list of ‘medicalized’, specialty-driven labels that continues to expand includes fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivity, and many others.”

“…These labels fall under the general category of functional somatic syndromes and seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones. However, using DSM criteria, virtually all these functional syndromes would fall into the somatoform disorders category given their phenomenology, unknown physical causes, absence of reliable markers, and the frequent coexistence of somatic and psychiatric symptoms.”

In Table 1, under the heading “Functional Somatic Syndromes (FSS)” Escobar and Marin list:

“Irritable bowel syndrome, Chronic fatigue syndrome, Fibromyalgia, Multiple chemical sensitivity, Nonspecific chest pain, Premenstrual disorder, Non-ulcer dyspepsia, Repetitive strain injury, Tension headache, Temporomandibular joint disorder, Atypical facial pain, Hyperventilation syndrome, Globus syndrome, Sick building syndrome, Chronic pelvic pain, Chronic whiplash syndrome, Chronic Lyme disease, Silicone breast implant effects, Candidiasis hypersensivity, Food allergy, Gulf War syndrome, Mitral valve prolapse, Hypoglycemia, Chronic low back pain, Dizziness, Interstitial cystitis, Tinnitus, Pseudoseizures, Insomnia, Systemic yeast infection, Total allergy syndrome”

This radical proposal for a “Complex Somatic Symptom Disorder” category will provide a convenient dustbin into which these diverse disorders might be shovelled.

It will expand the markets for antidepressant and antipsychotic drugs and therapies such as CBT to address perceptions of

           …poor adjustment…disproportionate distress and disability…dysfunctional and maladaptive response…unhelpful illness beliefs…activity avoidance…psychological distress in the wake of a general medical condition…personality traits…poor coping strategies contributing to worsening of a medical condition…sick role behaviour…secondary gains…

and other perceived barriers to “adjustment” or “rehabilitation”.

It will provide an attractive means of reducing the financial burden to governments and health insurers of providing appropriate medical investigations, medical treatments, financial and social support.

Whilst the proposals suggest that:

“a diagnosis of CSSD is inappropriate in the presence of only unexplained medical symptoms. Similarly, in conditions such as irritable bowel syndrome, CSSD should not be coded unless the other criterion (criterion B—attributions, etc) is present”

the application of an additional diagnosis of “Complex Somatic Symptom Disorder” will be based on subjective measures of whether the patient is perceived as having “dysfunctional and maladaptive beliefs” or “cognitive distortions” about their symptoms or disease resulting in “Misattributions [and] excessive concern or preoccupation with symptoms and illness”, whether the patient is “catastrophising” or has adopted “the sick role”.

Misidentification will increase the application of inappropriate treatment regimes – antidepressants and antipsychotic drugs, and therapies such as CBT to modify “dysfunctional and maladaptive beliefs” about the patient’s symptoms and disease, and behavioral techniques and “to alter illness and sick role behaviors and promote more effective coping”.

Get it wrong and patients are exposed to the risk of iatrogenic disease.

Get it wrong and there will be implications for the securing of health insurance, welfare, social care packages, disability and workplace adaptations and provision of education tailored to the needs of children too sick to access mainstream school.

Get it wrong and families will be put at increased risk of wrongful accusation of “factitious disorder by proxy/factitious disorder on other”.

Get it wrong and practitioners are at risk of litigation.

The CFIDS Association of America [3] has submitted:

“As drafted, the criteria for CSSD establish a “Catch-22” paradox in which six months or more of a single or multiple somatic symptoms – surely a distressing situation for a previously active individual – is classified as a mental disorder if the individual becomes “excessively” concerned about his or her health. Without establishing what “normal” behavior in response to the sustained loss of physical health and function would be and in the absence of an objective measure of what would constitute excessiveness, the creation of this category poses almost certain risk to patients without providing any offsetting improvement in diagnostic clarity or targeted treatment.”

and

“This is especially true with regard to patients coping with conditions characterized by unexplained medical symptoms, or individuals with medical conditions that presently lack a mature clinical testing regimen that provides the evidence required to substantiate the medical seriousness of their symptoms. For instance, all of the case definitions for CFS published since 1988 have required that in order to be classified/diagnosed as CFS, symptoms must produce substantial impact on the patient’s ability to engage in previous levels of occupational, educational, personal, social or leisure activity. Yet, all of the case definitions rely on patient report as evidence of the disabling nature of symptoms, rather than results of specific medical tests. So by definition, CFS patients will meet the CSSD criteria A and C for somatic symptoms and chronicity, and by virtue of the lack of widely available objective clinical tests sensitive and specific to its characteristic symptoms, CFS patients may also meet criterion B-4.”

The UK patient organisation, the 25% ME Group [4] has submitted:

“There is international concern that the proposed diagnostic category of CSSD as it is currently defined will be used to incorrectly diagnose ME/CFS patients with a psychiatric disorder.”

and

“It is of note that the draft of the proposed new category of CSSD states: “Having somatic symptoms of unclear aetiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptoms disorder diagnosis” (APA Somatic Symptom Disorders, 29th January 2010) but no such assurance is offered with respect to ME/CFS. This needs to be rectified.”

I call on the Somatic Symptom Disorders Work Group to give urgent reconsideration to their proposal for a new category “Complex Somatic Symptom Disorder” – while there’s still time to put it right.

Suzy Chapman, UK patient advocate

[1] Escobar, Javier I., M.D., M.Sc. DSM-5 Task Force Member Biosketch and Disclosure information:
http://www.dsm5.org/MeetUs/Documents…%201-11-10.pdf

[2] Marin H, Escobar JI: Unexplained Physical Symptoms What’s a Psychiatrist to Do? Psychiatric Times. Aug 2008, Vol. 25 No. 9: http://www.psychiatrictimes.com/disp…/10168/1171223

[3] CFIDS Association of America submission to the DSM-5 public review: http://www.cfids.org/advocacy/2010/dsm5-statement.pdf

[4] 25% ME Group submission to the DSM-5 public review: http://www.25megroup.org/News/DSM-V%20submission.doc  

Submitted by Suzy Chapman, UK

In response to: Overall Comments

Although the Diagnostic and Statistical Manual of Mental Disorders does not have quite the relevance for UK and some European patient populations as it does for the USA, diagnostic criteria in the forthcoming edition will shape the international research and literature landscapes for many years to come. DSM-5 will influence not only how disorders are defined for international research purposes but how patients and their needs are perceived by those responsible for their medical treatment and social care. It is hoped then, that the views of those from outside the USA submitting comment in response to the preliminary draft revisions will be afforded due consideration.

I would like to raise the following points in this “Overall Comment” section:

I welcome the decision of the Task Force to extend the submission of responses to preliminary draft revisions to the lay public as well as to APA members, clinicians, allied health professionals, researchers, administrators and other end users and for the Task Force’s recognition that patients, their carers, families and advocates and the patient organisations that represent their interests are crucial stakeholders in any consultation process. Their input merits particular consideration given the absence of patient representation within the individual Work Groups.

Professionals within the field will have been alerted to the public review process well in advance of 10th February; some specific patient groups will have already been interacting with relevant Work Groups with the opportunity of informing the revision process prior to the release of draft proposals. But whilst those patient communities with organised and vocal advocates will have used the internet and other channels of communication to alert their interest groups there may be many patient groups for which awareness of the DSM-5 development process and the opportunity to review proposals and submit responses may have taken a while to come to their attention.

Additionally, patient representation organisations would have benefited from more time in which to consult with external advisers and their own members, following the release of proposals, in order that the views of their members might be sought to inform their responses. This is particularly relevant since from 2007, when the Work Groups were formed, just two progress reports have been published by the various Work Groups, which in many cases have been notable for their brevity and lack of detail.

Some Work Groups, for example, the Work Group for Somatic Symptom Disorders, have published reports and editorials in subscription journals which have discussed and expanded on the proposals in the brief progress updates. But these journal reports, editorials and commentaries have not always been readily available to those outside the field and without journal paper access.

It would have been helpful, for example, if the publication of the free access Editorial: Dimsdale J, Creed F: The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report on behalf of the Somatic Symptom Disorders Work Group in the June ‘09 edition of J Psychosom Res, 66 (2009) 473–476 could have been noted on the Somatic Symptom Disorders Work Group Progress Report page for wider dissemination.

I consider that the period for public review should have been at least a full three months in order enable better participation by patient interest groups.

It is understood from the current DSM-5 Timeline that the next opportunity for public review will be during May-July 2011, when revised draft diagnostic criteria will be posted online for approximately one month, following the internal review, to allow the public to provide feedback.

For the reasons above, I suggest that the Task Force gives consideration to extending this beta review period from one month to at least two months.

It is possible that I may have overlooked it, but I have noted no reference on the DSM-5 website to the submitting of comments through any other means than via the webpage text editor, for which registration is required. I have received a number of reports from patients of the difficulties they have experienced both with the registration process and with uploading comment. I would like to have seen the option for responses to be submitted via email and also via paper letter. This would also have been more inclusive of those who prefer not to use electronic means because of limited access to, or lack of confidence with, computers or whose access to computers is restricted due to ill health or disability.

Perhaps the issue of inclusivity can be addressed before the 2011 review period?

My experience of participation in previous consultation exercises has been limited to formal consultation processes where stakeholders have been required to register an interest, where responses to a draft or consultation document have been acknowledged and where, in some cases, there has been a commitment on the part of the document development group to respond publicly to responses received.

I acknowledge that the Task Force has had to balance opening up the draft proposals review process to a wide range of stakeholders against conducting a more restricted consultation process in which responses are acknowledged, recorded and responded to. It is, however, disconcerting for both professionals and the lay public to tender responses into which considerable effort may have been invested where there is no real understanding of how those responses are to be collated, considered and used to inform any revisions to the drafts prior to the commencement of field trials and with the knowledge that their comments and concerns will not be visible for scrutiny by other stakeholders.

Does the Task Force have any plans to publish summaries of the key areas of concern brought to their attention via the public review process for each of the Work Groups’ proposals and to publish Work Group/Task Force responses?

The APA continues to participate with the WHO in a DSM-ICD Harmonization Coordination Group and in the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, chaired by DSM-5 Task Force member, Steven Hyman, MD.

To date, five meetings of the Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders have been held in Geneva. Summaries of the first four meetings held since 2007 have been published on the WHO main website. (A summary of the last meeting which took place over six months ago, in September 2009, has still to be published.)

It was raised, last year, with the Task Force, that since the DSM-5 Task Force participates in the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders and a DSM-ICD Harmonization Coordination Group that consideration should be given to publishing copies of the summaries of these meetings on the DSM-5 pages as well as on the WHO website. No response from the DSM-5 Task Force to this suggestion was forthcoming.

Would the Task Force please give further consideration to this suggestion?

ICD-11 and DSM-V focussed editorials and articles in Advances in Psychiatric Treatment, Jan 10

ICD-11 and DSM-V (DSM-5) focussed editorials and articles in January 2010 edition of Advances in Psychiatric Treatment

Post #11 Shortlink: http://wp.me/pKrrB-up

In the January 2010, Volume 16, Issue 1 edition of Advances in Psychiatric Treatment there are two editorials and an article around ICD-11 and DSM-V (DSM-5) revision classificatory issues.

The Bouch editorial commentary, the Sartorius editorial and the Thornicroft et al article all include brief references to “chronic fatigue syndrome”.

[Subscription or payment required for access to full editorials and articles.]

Adv. Psychiatr. Treat., Jan 2010; 16: 1.

FROM THE EDITOR

Joe Bouch: Classification

[No abstract available]

“….Nevertheless, as diagnosis is intended to be one of the strongest assets of a psychiatrist (Tyrer 2009), clinicians need to think about and be involved in the forthcoming revisions and harmonisation of the two major classifications ICD and DSM. Sartorius (pp. 2-9) gives a behind-the-scenes view of the revision process. There are many vested interests: not just clinicians, but governments and NGOs, lawyers, researchers, public health practitioners, Big Pharma and patient groups. Vast sums are at stake – everything from welfare benefits and compensation claims to research budgets. Concerns include the use of national classifications to facilitate political abuse and of diagnostic labels that are seen as stigmatising or are used to stigmatise. Like Sartorius, Thornicroft (pp. 53-59) singles out chronic fatigue syndrome, bitterly contested in terms of its status as a physical, psychiatric or psychosomatic condition and viewed by healthcare staff as a less deserving category.

“Should the classifications use categories or dimensions? A dimensional approach seems impractical, although dimensions could be used to augment categorical definitions, as with severity of depression…”

Advances in Psychiatric Treatment (2010) 16: 2-9. doi:10.1192/apt.bp.109.007138

Revision of the classification of mental disorders in ICD-11 and DSM-V: work in progress

Editorial: Norman Sartorius

“…In ICD-10 (World Health Organization 1992a), the chapter dealing with mental disorders contains several categories that appear in other chapters as well. Thus, dementia can be found in the chapter of mental disorders, because of its predominantly psychiatric symptoms, and in the chapter of neurological diseases, because it is a brain disease that can be the cause of death. A number of the psychiatric syndromes that occur in the course of other diseases are listed in the chapter of mental disorders as well as in chapters describing other conditions. For example, general paresis is listed in the chapter of mental disorders and in the chapter dealing with syphilis and other contagious diseases. Some of the categories that one would expect to find in a chapter devoted to mental disorders have been placed elsewhere, mainly because of pressures exerted by those who did not want to be labelled by any particular psychiatric diagnosis. Thus, for example, chronic fatigue syndrome, which was listed together with neurasthenia for a long time, is now in the chapter containing infectious diseases which are supposed to be causing it*, and premenstrual dysphoric states are in the chapter dealing with gynaecological disorders…”

*Ed:It’s unclear what Sartorius means, here:

Chronic fatigue syndrome is indexed in Volume 3: The Alphabetical Index to G93.3: Chapter VI: Diseases of the nervous system (G00-G99) > Other disorders of the nervous system (G90-99) > G93 Other disorders of brain > G93.3: Postviral fatigue syndrome; Benign myalgic encephalomyelitis.

Abstract:

Revision of the classification of mental disorders in ICD-11 and DSM-V: work in progress

Norman Sartorius

Norman Sartorius is President of the Association for the Improvement of Mental Health Programmes and holds professorial appointments at the Universities of London, Prague and Zagreb and at several other universities in the USA and China. Dr Sartorius was a member of the WHO’s Topic Advisory Group for ICD-11 and a consultant to the American Psychiatric Research Institute, which supports the work on the DSM-V. He has also served as Director of the Division of Mental Health of the WHO and was the principal investigator of several major international studies on schizophrenia, on depression and on health service delivery. He is a past President of the World Psychiatric Association and of the Association of European Psychiatrists.

Correspondence: Correspondence Professor N. Sartorius, 14, chemin Colladon, 1209 Geneva, Switzerland. Email: sartorius@normansartorius.com

This editorial summarises the work done to prepare ICD-11 and DSM-V (which should be published in 2015 and 2013 respectively). It gives a brief description of the structures that have been put in place by the World Health Organization and by the American Psychiatric Association and lists the issues and challenges that face the two organisations on their road to the revisions of the classifications. These include dilemmas about the ways of presentation of the revisions (e.g. whether dimensions should be added to categories or even replace them), about different versions of the classifications (e.g. the primary care and research versions), about ways to ensure that the best of evidence as well as experience are taken into account in drafting the revision and many other issues that will have to be resolved in the immediate future.

Advances in Psychiatric Treatment (2010) 16: 14-19. doi:10.1192/apt.bp.109.007120

The classification of mental disorder: a simpler system for DSM-V and ICD-11

David Goldberg

Sir David Goldberg is Professor Emeritus and a Fellow of King’s College London. He has devoted his professional life to improving the teaching of psychological skills to doctors of all kinds, and to improving the quality of services for people with severe mental illness. After completing his psychiatric training at the Maudsley Hospital, he went to Manchester, where for 24 years he was Head of the Department of Psychiatry and Behavioural Science. In 1993 he returned to the Maudsley as Professor of Psychiatry and Director of Research and Development.

Correspondence: Correspondence Professor Sir David Goldberg, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Email: David.Goldberg@iop.kcl.ac.uk

This article proposes a simplification to the chapter structure of current classifications of mental disorder, which cause unnecessary estimates of ‘comorbidity’ and pay major attention to symptom similarity as a criterion for deciding on groupings. A simpler system, taking account of recent developments in aetiology, is proposed. There is at present no simple solution to the problems posed by the structure of our classification, but the advantages as well as the shortcomings of changing our approach to diagnosis are discussed.

Related material in APT:

Advances in Psychiatric Treatment (2010) 16: 53-59. doi:10.1192/apt.bp.107.004481

Discrimination against people with mental illness: what can psychiatrists do?

Graham Thornicroft, Diana Rose and Nisha Mehta

“…Other diagnostic groups also appear to be less popular with healthcare staff. Chronic fatigue syndrome is bitterly contested in terms of its status as a physical, psychiatric or psychosomatic condition and arouses controversy about its causation and treatment. People who have been given or assumed this diagnosis often describe experiences of rejection by both general and mental health staff Davidson 2005)…”

Discrimination against people with mental illness: what can psychiatrists do?

Graham Thornicroft, Diana Rose and Nisha Mehta

Graham Thornicroft is Professor of Community Psychiatry at the Institute of Psychiatry, King’s College London, and a consultant psychiatrist and Director of Research and Development at the South London and Maudsley NHS Foundation Trust. Diana Rose is a senior lecturer and Co-Director of the Service User Research Enterprise, Institute of Psychiatry, which conducts service-user led research in the field of mental health. Professor Thornicroft and Dr Rose are also members of the National Institute for Health Research Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust/ Institute of Psychiatry, and are supported by the NIHR Sapphire Applied Research Programme. Nisha Mehta is a medical student at the School of Medicine, King’s College London, and is undertaking research related to stigma, discrimination and mental health.

Correspondence: Correspondence Professor Graham Thornicroft, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Email: graham.thornicroft@kcl.ac.uk

This article discusses the evidence that experiences of stigmatisation and discrimination among people with mental illnesses are common and may be severe. Furthermore, there are growing concerns that people with mental illness receive second-class physical healthcare. Beyond this, some aspects of psychiatric practice are reported as being insensitive, disrespectful or even disabling. We consider whether such claims are justified and what psychiatrists can do, directly and indirectly, to reduce stigma and discrimination and improve our practice.

Notes:

1] The APA now plans to publish draft proposals for changes to diagnostic criteria on 10 February. The Alpha Draft for ICD-11 is currently timelined for May 2010.

2] DSM-V Somatic Symptom Disorders Work Group proposals so far can be found at: DSM-5 and ICD-11 Watch at: http://wp.me/PKrrB-hT

3] The Academy of Psychosomatic Medicine November ’09 Annual Meeting slide presentations here:

Francis Creed, MD, FRCP: Can We Now Explain Medically Unexplained Symptoms?


PDF Creed Presentation Slides (No transcript)

      Creed Presentation Slides

       Creed References

(A lengthy but important slide presentation by DSM-V Somatic Symptom Disorders Work Group member, Francis Creed. No transcript available but please view the slides – there are many references to “Chronic fatigue syndrome”, chronic fatigue and IBS and to the so called “Functional Somatic Syndromes”.)

Lawson Wulsin, MD, FAPM, DSM V for Psychosomatic Medicine: Current Progress and Controversies

      Wulsin Presentation Slides

[No transcript available]

Joel Dimsdale, MD, FAPM, Update on DSM V Somatic Symptoms Workgroup

       Dimsdale text 

[Text version of slides]

4] For detailed information on the proposed structure of ICD-11, the Content Model and operation of iCAT, the collaborative authoring platform through which the WHO will be revising ICD-10, please scrutinise key documents on the ICD11 Revision Google site:

https://sites.google.com/site/icd11revision/
https://sites.google.com/site/icd11revision/home/documents

APM Workshop: DSM-V for Psychosomatic Medicine: Current Progress and Controversies

APM 2009 Annual Meeting Workshop: DSM-V for Psychosomatic Medicine: Current Progress and Controversies

Post #8 Shortlink: http://wp.me/pKrrB-hc

In November, last year, The Academy of Psychosomatic Medicine, Bethesda, Maryland, held its drug company sponsored 56th Annual Meeting in Las Vegas, Nevada.

Three DSM-V Work Group members, Francis Creed, Lawson Wulsin and Joel Dimsdale (Chair, Somatic Symptom Disorders Work Group) gave presentations around “Medically Unexplained Symptoms” (MUS) and DSM-V, and DSM-V proposals and progress. Slides are available, below, for the first two presentations, with text for the third.

This material represents the most recent information around the deliberations of the DSM-V Work Group that is revising the categories currently under DSM-IV “Somatoform Disorders”.

See this Dx Revision Watch page for previous updates from this Work Group.

The APA anticipates publishing draft proposals for DSM-V diagnostic categories on 20 January. (Since rescheduled for 10 February 2010.)

The Academy of Psychosomatic Medicine

Bethesda, Maryland, US
The Organization for Consultation and Liaison Psychiatry
Publishers of Psychosomatics

2009 ANNUAL MEETING in LAS VEGAS
November 11–14, 2009

56th Annual Meeting

“The Academy of Psychosomatic Medicine recognizes and appreciates the significant financial support provided by the following companies for the 56th Annual Meeting.

“AstraZeneca Pharmaceuticals
Bristol-Myers Squibb and Otsuka Pharmaceutical, Inc.
Eli Lilly and Company
Ortho-McNeil Janssen Scientific Affairs, LLC”

PRESENTERS’ SLIDES

Award Lectures

Hackett Award — Friday, 12:45pm – 1:45pm

Francis Creed, MD, FRCP: Can We Now Explain Medically Unexplained Symptoms? [1]

      Creed Presentation Slides

       Creed References

[No transcript available]

Workshops

Workshop 15 — Saturday, 1:45 – 2:45pm

DSM-V for Psychosomatic Medicine: Current Progress and Controversies

Lawson Wulsin, MD, FAPM: DSM V for Psychosomatic Medicine: Current Progress and Controversies [2]

     Wulsin Presentation Slides

[No transcript available]

Joel Dimsdale, MD, FAPM: Update on DSM V Somatic Symptoms Workgroup [3]

       Dimsdale text

[Text version of slides]

Update on DSM V Somatic Symptoms Workgroup

Workshop #15, APM Annual Meeting, 11-14-09
DSM-V for Psychosomatic Medicine: Current Progress and Controversies

The Somatic Symptoms Workgroup was charged with reviewing most somatoform disorders, psychological factors affecting medical condition, and factitious disorders. There is considerable confusion regarding the diagnostic terminology and a reluctance to use these diagnostic labels. In addition to relying on expert opinion and the research literature, the Workgroup has also been conducting studies in an effort to learn how physicians actually use these diagnostic labels.

These diagnoses are rarely coded. In a study of >1,000,000 Virginia Anthem Blue Cross policy holders, Levenson [4] found that there were fewer than 600 patients with such disorders. Of these 600 patients, the largest group of patients were diagnosed with Psychological Factors Affecting Medical Condition.

Four focus groups were held in San Diego and Edinburgh. Psychiatrists from very different practice settings attended these groups (child psychiatrists, forensic psychiatrists, psychopharmacologists, consultation psychiatrists, psychotherapists). Nonpsychiatrist attendees included neurologists, pediatricians, and gastroenterologists. Using themes identified from the focus groups, an anonymous internet poll was designed. Using mailing lists from a variety of professional organizations, physicians were invited to respond to an anonymous poll.

Three hundred thirty-two physicians responded to the poll. Two thirds were psychiatrists; two-thirds were from the United States. While in general, physicians reported that somatoform patients were relatively rare in their practices (i.e. 0-2%), some physicians reported high prevalence of these patients. Over 30% of the physicians regarded the diagnostic guidelines for pain disorder and somatoform disorder not otherwise specified as “unclear.” Similar numbers of doctors regarded these particular disorders as “not useful.” Physicians were uniform in their opinion that patients disapproved of such diagnostic labels. Respondents also felt that there was a great deal of overlap between somatization disorder, pain disorder, hypochondriasis, and somatoform disorder not otherwise specified. In addition, they felt that that there was overlap between the somatoform disorders and anxiety and depressive disorders.

The Somatic Symptoms Workgroup has been struck by the fact that “medically unexplained symptoms” (MUS) comprise the crucial intellectual underpinning of the large group of somatoform disorders; yet MUS designations are perilous. They foster mind-body dualism; they confuse “undiagnosed” with “unexplained”; they contribute to doctor-patient antagonism; and they base a diagnosis on a negative, rather than positive criteria.

The Workgroup is proposing a series of changes to these disorders. First off, such disorders would be grouped together under one rubric entitled “Somatic Symptom Disorders”, which would include somatoform disorders, factitious disorders, and psychological factors affecting medical condition. Second, because of their many common features, the group is proposing that hypochondriasis, pain disorder, somatization disorder, and undifferentiated somatoform disorder be grouped together as “Complex Somatic Symptom Disorder”, with optional specifyers to designate when the predominant presentation is, for instance, hypochondriasis, etc. MUS is de-emphasized for this diagnosis, which would require both prominent somatic symptoms causing distress or dysfunction, as well as positive psychological criteria (behavior, cognition, perception).

A draft description of these and other disorders will be published on the APA’s DSM V website in January, 2010.

In addition, a paper describing the thinking of the workgroup and providing a slightly earlier version of the diagnostic guidelines may be found at:

Dimsdale J , Creed F, and on behalf of the DSM-V Workgroup on Somatic Symptom Disorders. The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV—a preliminary report, J Psychosom Res, 66 (2009) 473–476

[Ed: Free full text here: http://www.jpsychores.com/article/S0022-3999(09)00088-9/fulltext ]

The workgroup welcomes comments from colleagues about the proposed changes. Are the proposed changes on the right track? Does this proposal represent, all in all, a step forward? Are there major adverse unintended consequences? Workgroup members include: Arthur Barsky, Francis Creed, Javier Escobar, Nancy Frasure-Smith, Michael Irwin, Frank Keefe, Sing Lee, James Levenson, Michael Sharpe [5], Lawson Wulsin, Joel Dimsdale (chair).

Please send comments to Joel Dimsdale via email jdimsdale@ucsd.edu .

[Ends]

[1] Francis Creed, MD, is a member of the DSM-V Somatic Symptom Disorders Work Group (aka Somatic Distress Disorders Work Group) and was a member of the international CISSD Project, co-ordinated by Dr Richard Sykes, PhD. He is a co-editor of the Journal of Psychosomatic Research.

[2] Lawson R. Wulsin, MD, is a member of the DSM-V Somatic Symptom Disorders Work Group.

[3] Joel E Dimsdale, MD, chairs the DSM-V Somatic Symptom Disorders Work Group, is a member of the DSM-V Task Force and was a member of the CISSD Project.

[4] James L Levinson, MD, is a member of the DSM-V Somatic Symptom Disorders Work Group and was a member of the CISSD Project.

[5] Michael Sharpe, MD, Director, University of Edinburgh Psychological Medicine Research Group, is a member of the Somatic Symptom Disorders Work Group, a co-PI of the UK MRC funded PACE Trial and was a member of the CISSD Project.

 

Related information:

The current use of the diagnosis “Psychological Factors Affecting Medical Condition” in DSM-IV is set out here

Francis Creed is currently working with EACLPP colleagues, Henningsen and Fink, on a draft white paper for the EACLPP MUS Study Group called: “Patients with medically unexplained symptoms and somatisation – a challenge for European health care systems”. A copy of the MUS Study Group working draft can be downloaded from the EACLPP site.

The January 2010, Editorial “Is there a better term than “Medically unexplained symptoms?” Creed F, Guthrie E, Fink P, Henningsen P, Rief W, Sharpe M, White P. J Psychoso Res: Volume 68, Issue 1, Pages 5-8, discusses the deliberations of the EACLPP study group. The Editorial also includes references to the DSM and ICD revision processes.

Javier Escobar, MD, Director of the University of Medicine and Dentistry of New Jersey (UMDNJ) – Robert Wood Johnson Medical School (RWJMS) Medically Unexplained Physical Symptoms (MUPS) Research Center, which has been supported with over $4M in funding by the US National Institute of Mental Health (NIMH), is a member of the DSM-V Task Force. Dr Escobar serves as a Task Force liaison to the Somatic Symptom Disorders Work Group and is said to work closely with this group.

In a 2008 Special Report by Marin and Escobar: “Unexplained Physical Symptoms What’s a Psychiatrist to Do?” Psychiatric Times. Vol. 25 No. 9, August 1, 2008, the authors write:

“…Perhaps as a corollary of turf issues, general medicine and medical specialties started carving these syndromes with their own tools. The resulting list of ‘medicalized’, specialty-driven labels that continues to expand includes fibromyalgia, chronic fatigue syndome, multiple chemical sensitivity, and many others.

“…These labels fall under the general category of functional somatic syndromes and seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones. However, using DSM criteria, virtually all these functional syndromes would fall into the somatoform disorders category given their phenomenology, unknown physical causes, absence of reliable markers, and the frequent coexistence of somatic and psychiatric symptoms.”

In Table 1, under the heading “Functional Somatic Syndromes (FSS)” Escobar and Marin list:

“Irritable bowel syndrome, Chronic fatigue syndrome, Fibromyalgia, Multiple chemical sensitivity, Nonspecific chest pain, Premenstrual disorder, Non-ulcer dyspepsia, Repetitive strain injury, Tension headache, Temporomandibular joint disorder, Atypical facial pain, Hyperventilation syndrome, Globus syndrome, Sick building syndrome, Chronic pelvic pain, Chronic whiplash syndrome, Chronic Lyme disease, Silicone breast implant effects, Candidiasis hypersensivity, Food allergy, Gulf War syndrome, Mitral valve prolapse, Hypoglycemia, Chronic low back pain, Dizziness, Interstitial cystitis, Tinnitus, Pseudoseizures, Insomnia, Systemic yeast infection, Total allergy syndrome”

Marin and Escobar August 2008 Special Report here on Psychiatric Times site.

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