‘Somatic Symptom Disorders in DSM-5: A step forward or a fall back?’ Eleanor Stein MD FRCP(C)

‘Somatic Symptom Disorders in DSM-5: A step forward or a fall back?’ Eleanor Stein MD FRCP(C) slide presentation

Post #233 Shortlink: http://wp.me/pKrrB-2Jt

Eleanor Stein MD FRCP(C) is a psychiatrist in private practice and a Clinical Assistant Professor in the Department of Psychiatry, University of Calgary, Canada.

In March, Dr Stein gave a presentation on the new Somatic Symptom Disorder category (as it had stood at the third draft) to the Alberta Psychiatric Association and has very kindly made her presentation slides available. These are in PDF format so no PowerPoint viewer is required.

Somatic Symptom Disorders in DSM-5 A step forward or a fall back?

Alberta Psychiatric Association March 23, 2013

    SSD Stein Presentation March 2013

The American Psychiatric Association is not affiliated with nor endorses this presentation.

The next edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders unwraps next month; finalized criteria sets are embargoed until May 22.

Until then, you will have to make do with the DSM-5 Table of Contents and Highlights of Changes from DSM-IV-TR to DSM-5 and the fact sheets and justifications on this APA webpage.

Erasing the interface between psychiatry and general medicine?

It’s four years, now, since I first started reporting on the deliberations of the Somatic Symptom Disorders Work Group.

The Somatoform Disorders section of DSM-IV has been dismantled and four rarely used disorders replaced for DSM-5 by a single new diagnosis, ‘Somatic Symptom Disorder’ (SSD).

From May, everyone with chronic medical illness or long-term pain becomes a potential candidate for this new mental disorder label.

Out go DSM-IV’s rigorous criteria sets and the requirement for multiple symptoms to be medically unexplained; in comes a far looser definition that doesn’t distinguish between ‘medically unexplained’ somatic symptoms or symptoms in association with diagnosed medical disease.

You can read APA’s rationale for the change here and here and Task Force Chair, David J Kupfer, defending the SSD work group’s decisions here, on Huffington Post.

For DSM-5, the SSD criteria set focuses on the psychological impact of persistent, distressing bodily symptoms on the patient’s thoughts, feelings and behaviours and the degree to which their response is perceived to be ‘disproportionate’ or ‘excessive’ – irrespective of symptom etiology.

Patients with common diseases like cancer, angina, diabetes, CVD, or multiple sclerosis; with long-term pain; with chronic illnesses and conditions like irritable bowel syndrome, fibromyalgia, CFS, interstitial cystitis, chronic Lyme disease, or persistent, somatic symptoms of unclear etiology may qualify for an additional mental disorder diagnosis if the clinician considers the patient also meets the criteria for ‘Somatic Symptom Disorder’ and may benefit from treatment  – psychotropic drugs, CBT or other therapies to modify ‘faulty illness beliefs’ and ‘maladaptive’ coping strategies.

“[The SSD Work Group’s] framework 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” [1]

“These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology 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 symptom disorder diagnosis. Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met.

“The symptoms may or may not be associated with a known medical condition. Symptoms may be specific (such as localized pain) or relatively non-specific (e.g. fatigue). The symptoms sometimes represent normal bodily sensations (e.g., orthostatic dizziness), or discomfort that does not generally signify serious disease.” [2]

*According to page 1 of APA document Highlights of Changes from DSM-IV-TR to DSM-5, under the heading “Terminology,” the document states: ‘The phrase “general medical condition” is replaced in DSM-5 with “another medical condition” where relevant across all disorders.’ Without better context for this change of terminology, it’s not clear what the implications might be or whether this might represent evidence of intent to blur the boundary between psychiatric and general medical conditions, or the colonization of general medicine. (If any readers are aware of earlier references to this change of terminology for DSM-5 and/or APA’s rationale, I should be pleased to receive information, as I can find no reference prior to January 21.)

Psychiatric creep

This new category will potentially result in a ‘bolt-on’ mental disorder diagnosis being applied to all chronic illnesses and medical conditions if the clinician decides the patient’s response to distressing bodily symptoms is ‘excessive’ or their coping strategies are ‘maladaptive,’ or that the patient is ‘catastrophising,’ or displaying ‘fear avoidance’ or is overly preoccupied with their symptoms (or in the case of a parent, a child’s symptoms).

If the practitioner feels the patient is spending too much time on the internet researching data, symptoms and treatments, or that their lives have become dominated by ‘illness worries,’ they may be vulnerable to dual-diagnosis with a mental disorder.

Patients with chronic, multiple bodily symptoms due to rare conditions or multi-system diseases like Behçet’s syndrome or Systemic lupus, which may take several years to diagnose, may be vulnerable to misdiagnosis with a mental disorder and premature case closure.

Families caring for children with chronic illness may be placed at risk of wrongful accusation of ‘over-involvement’ or of being ‘excessively concerned’ with a child’s symptoms or of colluding in the maintenance of ‘sick role behaviour.’

Just one distressing symptom for at least six months duration plus one of the three ‘B type’ criteria is all that is required to tick the box for a diagnosis of a mental health disorder – cancer + SSD; angina + SSD; asthma + SSD; COPD + SSD; diabetes + SSD; IBS + SSD; CFS + SSD…

15% of the ‘diagnosed illness’ study group (cancer and coronary disease) met the criteria for an additional diagnosis of SSD in the DSM-5 field trials.

In the ‘functional somatic’ study group (irritable bowel syndrome or chronic widespread pain), 26% were coded with SSD.

The criteria, as they stood at the third draft, caught 7% of the ‘healthy’ field trial control group.

The Somatic Symptom Disorder construct represents a significant change to the current DSM-IV-TR categories.

There is no substantial body of evidence to support the validity, reliability and safety of the application of SSD in adults or children nor any published data on projected prevalence rates across the entire disease spectrum or on the potential clinical and economic burdens for providers and payers – yet the SSD Work Group, Task Force and APA Board of Trustees have barrelled this through.

In February, SSD Work Group Chair, Joel E Dimsdale, MD, told journalist, Susan Donaldson James, for ABC News:

 “…If it doesn’t work, we’ll fix it in the DSM-5.1 or DSM-6.”

APA says there will be opportunities to reassess and revise DSM-5′s new disorders, post publication, and that it intends to start work on a DSM-5.1 release. Advocates and patient groups are not reassured by APA’s ‘publish first – patch later’ approach: is this science or Windows 7?

This section of DSM-5, seemingly overlooked by clinicians in the field, both within and outside psychiatry and psychosomatics, and by medico-legal and disability specialists demands scrutiny and investigation.

The SSD construct is now influencing emerging proposals and field testing for three severities of a new category for ICD-11, Bodily Distress Disorder, proposed to replace half a dozen existing ICD-10 Somatoform Disorders [3] [4].

As Dr James Brennan wrote in a recent BMJ Rapid Response:

“…All human distress occurs within the context of complicated factors (biological, psychological, emotional, interpersonal, social etc) and it is this context that demands our assessment and understanding, not reducing it all to a subjective judgment by a clinician as to whether a particular emotion is ‘excessive’ or ‘disproportionate’. How much distress ought a cancer patient to have? What democratic authority gives any of us the right to say what is excessive or proportionate about another person’s thoughts, emotions and behaviour? The SSD criteria in this regard are dangerously loose and over-inclusive.”

References

1 Dimsdale J, Creed F. 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 2009;66:473-6.

2 DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions PDF document, published May 4, 2011 for the second stakeholder review.

3 Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry 2012;24:556-67.

4 Goldberg DP. Comparison between ICD and DSM diagnostic systems for mental disorders. In: Sorel E, ed. 21st century global mental health. Jones & Bartlett Learning, 2012:37-53.

Further reading

APA Somatic Symptom Disorder Fact Sheet

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

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

Dimsdale JE. Medically unexplained symptoms: a treacherous foundation for somatoform disorders? Psychiatr Clin North Am 2011;34:511-3. [PMID: 21889675]