APA announces second public review of DSM-5 draft criteria and structure

American Psychiatric Association (APA) announces second public review of DSM-5 draft criteria and structure

Post #73 Shortlink: http://wp.me/pKrrB-12k

Second public stakeholder review and feedback period now 4 May to 15 June

APA News Release No: 11-27 PDF: http://tinyurl.com/APAnewsrelease4may11 

or open PDF on this site here: New Framework Proposed for Manual of Mental Disorders

Online posting of draft disorders and criteria proposed by the 13 DSM-5 Work Groups for new and existing mental disorders had originally been scheduled for May-June, this year. According to a revised Timeline on the APA’s DSM-5 Development site, in March, this second public review exercise had been rescheduled for August-September:

“August-September 2011: Online Posting of Revised Criteria. Following the internal review, revised draft diagnostic criteria will be posted online for approximately one month to allow the public to provide feedback. This site will be closed for feedback by midnight on September 30, 2011.”

But yesterday, 4 May, the APA announced that the second public review period is now open and will run from May to 15 June.

The DSM-5 site was updated yesterday with announcements and revised proposals (dated May 4, 2011) across all categories. The current review period closes on 15th June – just six weeks away.

Note that this is a public and stakeholder review and feedback exercise and is not restricted to professionals or members of the American Psychiatric Association.

There is a Task Force announcement here: http://www.dsm5.org/Pages/Default.aspx

[Extracts]

What Specifically Has Changed on This Site?

“You will notice several changes to this Web site since we first launched in February 2010. Numerous disorders contain updated criteria…

” ...Is There Opportunity to Provide Further Comments?

“At this time, we are asking visitors to review and comment on the proposed DSM-5 organizational structure and criteria changes. Please note that the current commenting period will end on June 15, 2011. It is important to remember that the proposed structure featured here is only a draft. These proposed headings were reviewed by the DSM-5 Task Force in November 2010…

“…The content on this site will stay in its current form until after completion of the DSM-5 Field Trials, scheduled to conclude later this year. Following analysis of field trial results, we will revise the proposed criteria as needed and, after appropriate review and approval, we will post these changes on this Web site. At that time, we will again open the site to a third round of comments from visitors, which will be systematically reviewed by each of the work groups for consideration of additional changes. Thus, the current commenting period is not the final opportunity for you to submit feedback, and subsequent revisions to DSM-5 proposals will be jointly informed by field trial findings as well as public commentary.

“We look forward to receiving your feedback during the coming weeks and appreciate your participation in this important process.”      [Source: http://www.dsm5.org/Pages/Default.aspx]

There are brief notes on the proposed DSM-5 Organizational Structure here:

http://www.dsm5.org/proposedrevision/Pages/proposed-dsm5-organizational-structure.aspx

The “Recent updates” page for “DSM changes” and “Disorder-specific changes” is here:

http://www.dsm5.org/Pages/RecentUpdates.aspx

 

Registration for submitting feedback

Last year, registration was required in order to submit comment via the DSM-5 Development website. You can register to submit feedback on the DSM-5 Development site home page or on the individual pages for specific category proposals (right hand side under “Participate”).

The revised Timeline can be read here: http://www.dsm5.org/about/Pages/Timeline.aspx

According to the Timeline, a third review and feedback is currently scheduled for January-February 2012, for two months.

 

Latest revisions for “Somatic Symptom Disorders”

http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx

I will post  information in the next posting specific to the proposals of the DSM-5  Work Group for “Somatic Symptom Disorders”

 

Media coverage of APA’s 4 May DSM-5 announcement

MedPage Today

CNN Blog

Washington Examiner: Corrupting Psychiatry by Max Borders

Washington Examiner: Corrupting Psychiatry by Max Borders

Post #58 Shortlink: http://wp.me/pKrrB-TU

Interesting commentary from writer Max Borders, last week, on the website of the Washington Examiner around the revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM):

Washington Examiner

Corrupting Psychiatry

By Max Borders 01/18/11 10:22 AM

The American Psychiatric Association (APA) has gone crazy — like a fox.

“There was a time when we could be more charitable about the vagaries in the APA’s Bible, the DSM. But not anymore. If you’ve never heard of the DSM, it’s the Diagnostic and Statistical Manual series the APA publishes. Psychiatrists all over the world use the DSM as a guidebook for treating people with some form of mental illness. But the APA may test credulity with its upcoming edition.

“I refer specifically to proposed changes in the DSM-V due out in 2013. It’s no accident these changes reflect new political realities about how psychiatric medicine gets paid for and by whom…”

Read rest of article at the Washington Examiner

Commentary in response to “Corrupting Psychiatry” from Dutch philosopher and psychologist, Maarten Maartensz, on Nederlog here More on the APA’s mockery of medicine and morality and here More on the APA and the DSM-5

Comments on Washington Examiner to article “Corrupting Psychiatry” by Max Borders

By: Skeeter
Jan 21, 2011 9:55 PM

Good article, that says things that need to be said, long and loud.

Both the APA, and the broader psychiatric profession, are currently indulging in a seriously unjustified power grab, and they and their claims are in desperate need of much closer and tougher (and ongoing) external scrutiny then they have been subject to date.

Generally speaking, I would have to agree that the profession is becoming much too closely aligned with and mutually reliant on both state and corporate interests, as opposed to the interests of the patient and the science on which they base their claims to authority.

One small point: I would not invoke British psychiatry as any counterbalance to the excesses of their American colleagues. The Brits have their own serious problems. Not least of which is that they are mired deep in the methodological and ethical swamp of somatoform disorders (aka conversion or psychosomatic disorders, and their related ‘treatments’), and a lot of patients are paying a very heavy price indeed for this obsession by certain influential members of the British psych establishment.

By: Suzy Chapman
Jan 22, 2011 7:28 AM

Erasing the interface between psychiatry and medicine

The previous commenter cautions against invoking members of the “British psych establishment”. Two very influential members of the British psychiatry and psychosomatics establishment, Professors Michael Sharpe and Francis Creed, have seats on the DSM-5 “Somatic Symptom Disorders” Work Group.

While many column inches by rightly perturbed journalists and a stream of often acerbic critiques from former DSM Task Force chairs, Allen Frances and Robert Spitzer, have focussed on the implications for introducing new additions into the DSM and broadening the definitions of existing diagnostic criteria, the DSM-5 “Somatic Symptom Disorders” Work Group (Chair, Joel E Dimsdale) has been quietly redefining DSM’s “Somatoform Disorders” categories with proposals that if approved would legitimise the application of an additional diagnosis of “Somatic Symptom Disorder” to all medical diseases and disorders.

Radical proposals for renaming the “Somatoform Disorders” category “Somatic Symptom Disorders” and combining a number of existing categories under a new umbrella, “Complex Somatic Symptom Disorder (CSSD)” and a more recently suggested “Simple Somatic Symptom Disorder (SSSD)”, have the potential for bringing millions more patients under a mental health banner and expanding markets for psychiatric services, antidepressants, antipsychotics and behavioural therapies such as Cognitive Behavioural Therapy (CBT) for all patients with somatic symptoms, irrespective of cause.

Professor Creed is co-editor of The Journal of Psychosomatic Research. In a June ’09 Editorial, titled “The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report”, which expanded on a brief DSM-5 Work Group progress report published on the DSM-5 Development website that April, Joel E Dimsdale and fellow DSM-5 Work Group member, Francis Creed, reported that by doing away with the “controversial concept of medically unexplained symptoms”, their 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.”

If the most recent “Somatic Symptom Disorders” Work Group proposals gain DSM Task Force approval, all medical conditions, whether “established general medical conditions or disorders” like diabetes or conditions presenting with “somatic symptoms of unclear etiology” will have the potential for a bolt-on diagnosis of “somatic symptom disorder”.

Under the guise of “eliminating stigma” and eradicating “terminology [that] enforces a dualism between psychiatric and medical conditions” the American Psychiatric Association (APA) appears hell bent on colonising the entire medical field by licensing the application of a mental health diagnosis to all medical diseases and disorders.

By: KAL
Jan 23, 2011 1:36 PM

Who else might benefit? Disability Insurance. If you can be shown to have a “mental illness” then disability insurance only pays a maximum of two years of payments vs. a lifetime of payments for an organic disease.

Check the APA website for conflicts of interest for members of the working group for Somatic Disorders.

References:

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

The most recent versions of the two key documents associated with the proposals of the “Somatic Symptom Disorders” Work Group are:

Update @ 7 February 2011

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

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

Descriptions document version 1/14/11 Revised Disorder Descriptions: Version 1/14/11

Rationale document version 10/4/10 Previous revised Justification of Criteria: Version 10/4/10

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

Revisions to DSM-5 proposals on 14.01.11: New category proposed “Simple Somatic Symptom Disorder”

Revisions to DSM-5 proposals on 14.01.11: New category proposed “Simple Somatic Symptom Disorder”

Post #56 Shortlink: http://wp.me/pKrrB-St 

DSM-5 Dustbin Diagnosis

For copies of International patient organisation and patient advocate submissions in the APA’s spring 2010 DSM-5 draft proposals review process see: http://wp.me/PKrrB-AQ

The page for current DSM-5 proposals for the “Somatoform Disorders” section of DSM-IV was updated on January 14, 2011 with a new category proposal called “Simple Somatic Symptom Disorder”.

Note this proposal is in addition to the recommendation of the Somatic Symptom Disorders Work Group, in February 2010, for grouping a number of existing disorders under a common rubric “Complex Somatic Symptom Disorder (CSSD)”  and it does not replace “CSSD”.

As I have been highlighting for some time now, under these DSM-5 Task Force proposals, all medical conditions, whether “established” general medical conditions or disorders, or conditions presenting with “somatic symptoms of unclear etiology”, have the potential for qualifying for an additional diagnosis of a “somatic symptom disorder”.

There have also been revisions and additions to some of the text of the “Disorder descriptions” document dated “DRAFT January 29, 2010” that was first published by the DSM-5 Task Force when draft proposals for revisions to DSM-IV were posted on the APA’s DSM-5 website on February 10, 2010, for public review and comment.

Note also that the key document: “Justification of Criteria-Somatic Symptoms DRAFT 1/29/10” which is also associated with the proposals of the Somatic Symptom Disorders Work Group has now been revised twice since February 2010.

Update @ 7 February 2011

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

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

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

What are the changes since draft proposals were released in February 2010?

On the APA’s DSM-5 Development web page:

http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

under “Somatoform Disorders Not Currently Listed in DSM-IV”

are now listed two proposals:

“Complex Somatic Symptom Disorder”

(which was discussed last year when the DSM-5 draft proposals were first released) and a new proposal:

“Simple Somatic Symptom Disorder”

See:

http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx  

Somatoform Disorders

 

Submissions 2010

International patient organisation and patient advocate submissions to DSM-5 draft proposals public review process, Feb-April 2010: http://wp.me/PKrrB-AQ

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?

Psychology Today: Allen Frances MD on DSM-5 and comment

Psychology Today: Allen Frances MD on DSM-5 draft proposals and comment

Post #32 Shortlink: http://wp.me/pKrrB-Fj

Over the past 12 months, Allen Francis, MD, has published a series of often controversial commentaries on the DSM revision process in the media, via Psychiatric Times website and yesterday, on the site of Psychology Today.

Dr Frances had been chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

I have had a comment published, this morning, in response to his latest piece on Psychology Today.

Blogs
DSM5 in Distress

The DSM’s impact on mental health practice and research.
by Allen Frances, MD

DSM5: An Open Process Or Bust
The next steps need help from the field and public.
Published on April 12, 2010

“The first drafts of DSM5 were posted two months ago, allowing the field and the public a first glimpse into what had previously been an inexplicably secretive process. Today is the last day for public comment on these drafts…”

Read full text here

Comments

Public review process

Submitted by Suzy Chapman on April 13, 2010 – 3:24am.

I would like to thank Dr Frances for his commentaries around the DSM revision process. I hope he won’t mind my highlighting that draft proposals are out for review until Tuesday, 20 April – so there is another week during which health professionals, researchers, patient organisations and the lay public can input into the review process.

For some time now, professionals in the field, interest groups and the media have voiced concerns that the broadening of criteria for some DSM-5 categories would bring many more patients under a mental health diagnosis.

But if the draft proposals of the “Somatic Symptom Disorders” Work Group were to be approved there will be medical, social and economic implications to the detriment of all patient populations and especially those bundled by many within the field of liaison psychiatry and psychosomatics under the so-called “Functional Somatic Syndromes” (FSS) and “Medically Unexplained Syndromes” (MUS) umbrellas, under which they include Chronic fatigue syndrome, ME, Fibromyalgia, IBS, chemical injury, chemical sensitivity, chronic Lyme disease, GWS and others [1].

There is considerable concern amongst international patient organisations 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 called “Somatic Symptom Disorders” and for the creation of a new classification, “Complex Somatic Symptom Disorder” (CSSD).

They are particularly concerned for patients living with conditions characterised by so-called “medically unexplained symptoms” or with medical conditions for which diagnostic tests are currently lacking that provide evidence substantiating the medical seriousness of their symptoms and the need for provision of appropriate medical investigations, treatments, financial and social support, and in the case of children and young people, the putting in place of arrangements for the education of children too sick to attend mainstream school.

According to “Somatic Symptom Disorders” Work Group proposals:

“To meet criteria for CSSD, criteria A, B, and C are necessary.

A. Somatic symptoms:

Multiple somatic symptoms that are distressing, or one severe symptom

B. Misattributions, excessive concern or preoccupation with symptoms and illness: At least two of the following are required to meet this criterion:

(1) High level of health-related anxiety.

(2) Normal bodily symptoms are viewed as threatening and harmful

(3) A tendency to assume the worst about their health (catastrophizing).

(4) Belief in the medical seriousness of their symptoms despite evidence to
the contrary.

(5) Health concerns assume a central role in their lives

C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic and persistent (at least six months).”

The CFIDS Association of America 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.” [2]

To date, there has been little public discussion by professionals or the media of the medical, social and economic implications for patients of the application of an additional diagnosis of “Complex Somatic Symptom Disorder”.

With a week to go before this initial public review period closes there is still time and I urge professionals and stakeholders to scrutinise the proposals of the “Somatic Symptom Disorder” Work Group and to submit their concerns to the Task Force.

Suzy Chapman, UK patient advocate

[1] 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/display/article/10168/1171223

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

—————————

Related material:

PULSE Today

Managing medically unexplained symptoms, 07 Apr 10

—————————

The DSM-5 public review period runs from 10 February to 20 April. Members of the public, patient representation organisations, professionals and other end users can submit responses, online.

Please take this opportunity to register comment and to alert and encourage professionals and international patient organisations to participate.

Proposed Draft Revisions to DSM Disorders and Criteria are published here on the APA’s relaunched DSM5.org website: http://www.dsm5.org/Pages/Default.aspx

Somatoform Disorders:
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx

Proposed new DSM-5 category: Complex Somatic Symptom Disorder
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=368

Two Key PDF documents are associated with proposals:

      PDF Somatic Symptom Disorders Introduction DRAFT 1/29/10

      PDF Justification of Criteria – Somatic Symptoms DRAFT 1/29/10

The Alpha Draft for ICD-11 is scheduled for May 2010. I shall be posting again shortly around the ICD-11 revision process.

%d bloggers like this: