APA website: New documents and videos on ‘Somatic Symptom Disorder; article: Psychiatric News

APA website: New documents and videos on ‘Somatic Symptom Disorder; article: Psychiatric News

Post #228 Shortlink: http://wp.me/pKrrB-2Gi

Updates at March 7

Article in Die Psychiatrie

Somatic Symptom Disorders: a new approach in DSM-5

J. E. Dimsdale, University of California, San Diego, DSM Task force, Somatic Symptoms Work Group

Die Psychiatrie 2013; 10: 30–32


Following a brief historic discourse, problems with the current use and concepts the of somatoform disorders are described. The rationale for substituting the term “somatoform” with “somatic symptom” in DSM5 is explained and the new classification criteria for the group of “somatic symptom related disorders” are described, which include severity ratings.

A special aspect is that “Illness anxiety disorder” is introduced as a new diagnostic entity in DSM-5.

“Störung mit somatischen Symptomen”: ein neuer Ansatz in DSM-5


Nach einem kurzen historischen Diskurs werden die Problembereiche und die Konzepte der somatoformen Störungen erläutert. Das Rational für einen Ersatz der “somatoformen” Störung durch eine “Störung mit somatischen Symptomen” in DSM5 wird erläutert. Die Klassifikationskriterien der Gruppe der “Störungen mit somatischen Symptomen” wird dargestellt.

Ein besonderer Aspekt ist die Einführung einer “Erkrankungsangst-Störung” in DSM-5.

Full paper can be downloaded here: http://bit.ly/W7filu

Doug Bremner, MD, comments on ‘Somatic Symptom Disorder’ here:

DSM-5 Somatic Symptoms Disorder is Going to Make Us All Mental

Doug Bremner | February 12, 2013


A number of new documents and short videos on ‘Somatic Symptom Disorder’ have been published on the APA’s new webpages, plus an article in Psychiatric News, published on March 1.

These are followed by recent, mainstream media coverage of concerns for all illness groups for the implications of misdiagnosis with ‘Somatic Symptom Disorder’ or for an additional diagnosis of ‘Somatic Symptom Disorder.’


Fact Sheet: Click link for PDF document   Somatic Symptom Disorder


Joel E Dimsdale, Chair, DSM-5 Somatic Symptom Disorders Work Group

What is Somatic Symptom Disorder?


What was the rationale behind changes to Somatic Symptom Disorder?


Will Somatic Symptom Disorder result in the missing of other medical problems?


Article: Psychiatric News (organ of the APA):


Psychiatric News | March 01, 2013
Volume 48 Number 5 page 7-7
American Psychiatric Association
Professional News

Somatic Chapter Drops Centrality Of Unexplained Medical Symptoms

Mark Moran

“…But Joel Dimsdale, M.D., chair of the Somatic Symptom and Related Disorders Work Group, emphasized that the most important change overall in this set of disorders is removal of the centrality of medically unexplained symptoms. “That was a defining characteristic of these disorders in DSM-IV, but we believe it was unhelpful and promoted a mind-body dualism that is hard to justify,” he told Psychiatric News.

So, for instance, the diagnosis of somatization disorder in DSM-IV was based on a long and complex symptom count of medically unexplained symptoms. DSM-5 criteria eliminate that requirement and recognize that individuals who meet criteria for somatic symptom disorder—the new designation, marked by disproportionate thoughts, feelings, and behaviors related to somatic symptoms—may or may not have a medically diagnosed condition.

Hypochondriasis has been eliminated; most individuals who would previously have been diagnosed with hypochondriasis have significant somatic symptoms in addition to their high health anxiety and should receive a DSM-5 diagnosis of somatic symptom disorder. Those with high health anxiety without somatic symptoms should receive a diagnosis of illness anxiety disorder…

Read full article here


Related material

Dimsdale JE. Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? Psychiatr Clin North Am, Volume 34, Issue 3, Pages 511-513 [PUBMED 21889675]

Overlapping Conditions Alliance (OCA)

“Members of the Overlapping Conditions Alliance (OCA) produced a white paper, Chronic Pain in Women: Neglect, Dismissal and Discrimination, to promote awareness and research of neglected and poorly understood chronic pain conditions that affect millions of American women. This report, which can be viewed and downloaded below, includes detailed policy recommendations to further these goals.” (Report 2010 and Report 2011)



Recent mainstream media coverage of the SSD issue

ABC News Radio:
Guidelines for Diagnosing Psychiatric Disorder May Overlook Physical Illnesses

ABC News:
New Psych Disorder Could Mislabel Sick as Mentally Ill

Canada.com and syndicated to a number of other Canadian media sites:
New “catch all” psychiatric disorder could label people who worry about their health as mentally ill

Fox News Health:
Does somatic symptom disorder really exist?

DSM-5 Task Force Chair, David J Kupfer, MD, defends the SSD construct on Huffington Post (but provides no answers to my questions):

David J. Kupfer, M.D. Chair, DSM-5 Task Force

Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care


American Psychiatric Association launches new pages for DSM-5 – DSM-5 to cost $199

American Psychiatric Association (APA) launches new pages for DSM-5 – DSM-5 to cost $199

Post #220 Shortlink: http://wp.me/pKrrB-2CD

Unless you’ve had your head stuck in a bucket this last three years, you’ll be aware that the next edition of the American Psychiatric Association’s diagnostic manual is slated for release this May.

APA has spent $25 million on the development of DSM-5.

DSM-5 will be published by American Psychiatric Publishing Inc. and planned for release at the APA’s 166th Annual Meeting in San Francisco (May 18-22).

A hardback copy is going to set you back $199, though paid up members of the American Psychiatric Association are being offered a discount.

Psychiatrists, psychologists, primary health care physicians, therapists, counselors, social workers and allied health professionals don’t have to use DSM-5.

Instead, when codes are required they can use the codes in Chapter 5 of ICD-9-CM (Mental Disorders) and Chapter 5 of ICD-10-CM (Mental, Behavioral and Neurodevelopmental disorders), when ICD-10-CM is implemented*.

*Effective implementation date for ICD-10-CM (and ICD-10-PCS) is currently October 1, 2014. Until that time the codes in ICD-10-CM are not valid for any purpose or use.

Image Copyright Dx Revision Watch 2013

Don’t like it? Don’t use it. Use ICD codes instead.

Since 2003, ICD-9-CM diagnostic codes have been mandated for third-party billing and reporting by HIPAA for all electronic transactions for billing and reimbursement. The codes in DSM are crosswalked to ICD codes.

So you can use ICD-9-CM codes.

And when ICD-10-CM is implemented, it isn’t going to cost you a cent – it will be freely available on the internet.

The ICD-10-CM draft, currently subject to partial code freeze, and its associated documentation can be accessed here on the CDC site; so you can already have a poke around:

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

On January 23, Allen Frances, MD, who had oversight of the Task Force that developed DSM-IV had this to say about the $199 manual:

Price Gouging: Why Will DSM-5 Cost $199 a Copy?


APA launches new pages for DSM-5

Last week the APA launched new pages to promote DSM-5.

Report by John Gever for Medpage Today:

Psych Group Posts Glimpses of Final DSM-5

John Gever, Senior Editor, MedPage Today | January 21, 2013

Peeks into the final DSM-5, the controversial new edition of the American Psychiatric Association’s diagnostic manual, are now available from the group prior to the guide’s official May 22 debut…

PR piece by Mark Moran for Psychiatric News, organ of the American Psychiatric Association:

Psychiatric News | January 18, 2013
Volume 48 Number 2 page 1-6
American Psychiatric Association
Professional News

Continuity and Changes Mark New Text of DSM-5

Mark Moran

The DSM-5 Task Force chair discusses conceptual themes driving changes to the new manual. This is the first in a series continuing through May that will summarize the diagnostic and organizational differences between DSM-IV and DSM-5.

DSM-5, approved by the APA Board of Trustees in December, reflects the “state of the clinical science” in psychiatric diagnosis, incorporating important findings from genetic, neurobiological, and treatment research, while also maintaining substantial continuity for maximum clinical utility…

Go here for the DSM-5 Collection.

Psychiatric News Alert, where those not intending to boycott DSM-5 are encouraged to explore and pre-order a copy ($199):

Psychiatric News Alert

Tuesday, January 22, 2013

New DSM-5 Series Includes Supplementary Information; Order Your Manual Now!

The new DSM-5 pages can be found here, with articles, fact sheets and videos:


Documents include:

DSM-5 Table of Contents  [Lists disorder sections and the categories that sit under them.]

Changes to DSM-5

Continuity and Changes Mark New Text of DSM-5, Psychiatric News, January 18, 2013

Highlights of Changes from DSM-IV-TR to DSM-5
DSM-5 Provides New Take on Developmental Disorders, Psychiatric News, January 18, 2013

DSM-5 Fact Sheets

From Planning to Publication: Developing DSM-5
The People Behind DSM-5
The Organization of DSM-5

Making a Case for New Disorders
Autism Spectrum Disorder
Specific Learning Disorder
Intellectual Disability
Social Communication Disorder
Attention-Deficit/Hyperactivity Disorder

DSM-5 Video Series

How and why was DSM-5 developed?
What has been the goal for revising DSM-5?

What are the changes to autism spectrum disorder in DSM-5?
What will be the impact of DSM-5 changes to autism spectrum disorder?
What are the changes to learning disorder in DSM-5?
What will be the impact of the revised specific learning disorder diagnosis?

The APA’s DSM-5 Development site can still be found here DSM-5 Development.

Proposals for changes to DSM-IV categories and criteria, as they had stood at the third draft, were frozen on June 15, 2012.

Any revisions made to criteria sets following closure of the third and final comment period are subject to embargo and the DSM-5 Development site has not been updated to reflect changes made to categories and criteria beyond June 15.

The entire third draft of proposals was removed from the DSM-5 Development site on November 15.

You can read APA’s rationale for removing the draft on an updated Permissions, Licensing & Reprints page.

Update on ICD-11 Beta draft: Bodily Distress Disorder

Updates on ICD-11 Beta draft: Bodily Distress Disorder (proposed for ICD-11 Chapter 5: Mental and behavioural disorders); Chronic fatigue syndrome; Postviral fatigue syndrome; Benign myalgic encephalomyelitis (Chapter 6: Diseases of the nervous system)

Post #218 Shortlink: http://wp.me/pKrrB-2Bg

Dr Elena Garralda presentation slides:


or open here: Click link for PDF document    Garralda presentation Somatization in Childhood

Slide 1

Somatization in childhood

The child psychiatrist’s concern?

Elena Garralda

CAP Faculty Meeting, RCPsych Manchester, September 2012

Slide 11

New ICD-11 and DSM-V classifications

. Somatoform disorders >>>
– Bodily distress syndrome (ICD-11)
– Complex Somatic symptom disorder (DSM-V)

[Preceded by downward pointing arrow]

“Unexplained” or “functional” medical symptoms (CFS, fibromyalgia, irritable bowel syndrome)

[Preceded by upward pointing arrow]

Physical complaint (s)
with subjective distress/preoccupation ++,
illness beliefs impairment
health help seeking


Notes on ICD-11 Beta drafting platform and DSM-5 draft by Suzy Chapman for Dx Revision Watch:

These notes may be reposted, if reposted in full, source credited, link provided, and date of publication included.

January 6, 2013

1] The publicly viewable version of the ICD-11 Beta drafting platform can be accessed here:
Foundation view: http://apps.who.int/classifications/icd11/browse/f/en
Linearization view: http://apps.who.int/classifications/icd11/browse/l-m/en

2] The various ICD-11 Revision Topic Advisory Groups are developing the Beta draft on a separate, more complex platform accessible only to ICD-11 Revision.

3] The ICD-11 Beta draft is a work in progress and not scheduled for completion until 2015/16. When viewing the public version of the Beta draft please note the ICD-11 Revision Caveats. Note also that not all proposals may be retained following analysis of the field trials for ICD-11 and ICD-11-PCH, the abridged Primary Care version of ICD-11:

4] The Bodily Distress Disorders section of the ICD-11 Beta draft Chapter 5 can be found here:

According to the public version of the ICD-11 Beta drafting platform, the existing ICD-10 Somatoform Disorders are currently proposed to be replaced with Bodily Distress Disorders, and Psychological and behavioural factors associated with disorders or diseases classified elsewhere, not with Bodily distress syndrome as Dr Garralda has in her slide presentation.

The following proposed ICD-11 categories are listed as child categories under parent, Bodily Distress Disorders, and Psychological and behavioural factors associated with disorders or diseases classified elsewhere:

EC5 Mild bodily distress disorder
EC6 Moderate bodily distress disorder
EC7 Severe bodily distress disorder
EC8 Psychological and behavioural factors associated with disorders or diseases classified elsewhere

There are no Definitions nor any other descriptors populated for the proposed, new ICD categories EC5 thru EC7.

EC8 is a legacy category from ICD-10 and has some populated content imported from ICD-10.

These earlier ICD-11 Beta draft Somatoform Disorders categories appear proposed to be eliminated and replaced with the four new categories EC5 thru EC8, listed above:

Somatization disorder [F45.0 in ICD-10]
Undifferentiated somatoform disorder [F45.1 in ICD-10]
Somatoform autonomic dysfunction [F45.3 in ICD-10]
Persistent somatoform pain disorder [F45.4 in ICD-10]
    > Persistent somatoform pain disorder
    > Chronic pain disorder with somatic and psychological factors [Not in ICD-10]
Other somatoform disorders [F45.8 in ICD-10]
Somatoform disorder, unspecified [F45.9 in ICD-10]

5] The existing ICD-10 Chapter V category Neurasthenia [ICD-10: F48.0] is no longer accounted for in the public version of the ICD-11 Beta draft. I have previously reported that for ICD-11-PHC, the Primary Care version of ICD-11, the proposal is to eliminate the term Neurasthenia.

(I cannot confirm whether the currently omission of Neurasthenia from the Beta draft is due to oversight or because ICD-11 Revision’s intention is that Neurasthenia is also eliminated from the main ICD-11 classification.)

6] I have previously reported that for ICD-11-PHC, the abridged, Primary Care version of ICD-11, the proposal, last year, was for a disorder section called Bodily distress disorders, under which would sit Bodily stress syndrome [sic].

This category is proposed for ICD-11 Primary Care version to include “milder somatic symptom disorders” as well as “DSM-5’s Complex somatic symptom disorder” and would replace “medically unexplained somatic symptoms.”

7] Dr Garralda lists Complex Somatic symptom disorder (DSM-V) on Slide 11 of her presentation.

The manual texts for the next edition of DSM are in the process of being finalized for a projected release date of May 2013. The next edition of DSM will be published under the title DSM-5 not DSM-V . The intention is that once published, updates and revisions to DSM-5 will be styled: DSM-5.1, DSM-5.2 etc.

When the third draft of DSM-5 was released in May 2012, the proposal was to merge Complex Somatic Symptom Disorder with Simple Somatic Symptom Disorder and to call this hybrid category Somatic Symptom Disorder.

This would mean that this new disorder has the same name as the overall disorder section it sits under, which replaces DSM-IV’s Somatoform Disorders.

As any subsequent changes to draft criteria sets following closure of the third stakeholder review are embargoed, I cannot confirm whether the SSD Work Group has decided to rename this category to Somatic symptom Disorder or retain the original term, Complex Somatic Symptom Disorder, the term used by Dr Garralda in her presentation.

8] Turning from ICD-11 Beta draft Chapter 5 Mental and behavioural disorders to Chapter 6 Diseases of the nervous system:

As previously reported, Chronic fatigue syndrome is listed under Diseases of the nervous system in the Foundation View. There is no listing for Chronic fatigue syndrome in the Linearization View nor is the term listed in the PDF for Chapter 6, that is available to those who are registered with ICD-11 Beta draft for access to additional content:


Documentation from the ICD-11 iCAT Alpha draft dating from May 2010, implies that the intention for ICD-11 is a change of hierarchy for the existing ICD-10 Title term Postviral fatigue syndrome.

In the ICD-11 Beta draft, Chronic fatigue syndrome (which was listed only within the Index volume of ICD-10 and not listed in Volume 2: The Tabular List) appears to be elevated to ICD Title term status, with potentially up to 12 descriptive parameters yet to be completed and populated in accordance with the ICD-11 “Content Model”.

But the current proposed hierarchical relationship between PVFS and CFS for ICD-11 remains unconfirmed.

See image for documentation from the iCAT Alpha drafting platform, from May 2010:


There is no discrete ICD Title term displaying for Postviral fatigue syndrome in either the ICD-11 Beta Foundation View or Linearization View.

Neither is there any discrete ICD Title term displaying for Benign myalgic encephalomyelitis in either the Foundation View or Linearization View.

Benign myalgic encephalomyelitis appears at the top of a list of terms under “Synonyms” in the CFS description. [The hover text over the asterisk at the end of “Benign myalgic encephalomyelitis” reads, “This term is an inclusion term in the linearizations.”]

Postviral fatigue syndrome is also listed under “Synonyms” along with a number of other terms imported from other classification systems.

Included in this list under “Synonyms” are “chronic fatigue syndrome nos” and “chronic fatigue, unspecified,” both of which appear to have been sourced from the as yet to be implemented, US specific, ICD-10-CM.

At some recent, unspecified date, a Definition has been inserted for ICD-11 Title term Chronic fatigue syndrome into the previously empty Definition field. An earlier Definition was removed when the Alpha draft was replaced with the Beta draft but can be seen in this screenshot, here, from June 2010:


The current Definition reads (and be mindful of the ICD-11 Caveats):

“Chronic fatigue syndrome is characterized by extreme chronic fatigue of an indeterminate cause, which is disabling andt [sic] does not improve with rest and that is exacerbated by physical or mental activity.”

There are no Definition fields for Benign myalgic encephalomyelitis or Postviral fatigue syndrome as these terms are listed under “Synonyms” to ICD-11 Title term, Chronic fatigue syndrome.

Since one needs to be mindful of the ICD-11 Caveats and as the Chair of Topic Advisory Group for Neurology has failed to respond to a request for clarification of the intention for these three terms and the proposed ICD relationships between them, I am not prepared to draw any conclusions from what can currently be seen in the Beta drafting platform.

I shall continue to monitor the Beta draft and report on any significant changes.

For definitions of “Synonyms,” “Inclusions,” “Exclusions” and other ICD-11 terminology see the iCAT Glossary:

Related material:


Presentation slides: Medically Unexplained Symptoms pages

Dr Graham Ash, Lancashire Care NHS Foundation Trust

Website pages featured in the slide presentation:

Medically Unexplained Symptoms


Dx Revision Watch Post, June 26, 2012: ICD-11 Beta drafting platform: Update (2): Neurasthenia, Postviral fatigue syndrome (PVFS), Benign myalgic encephalomyelitis (ME), Chronic fatigue syndrome (CFS), Fibromyalgia (FM), Irritable bowel syndrome (IBS): http://wp.me/pKrrB-2mC

Media coverage: APA Board of Trustees approves DSM-5 diagnostic criteria

Media coverage: American Pyschiatric Association Board of Trustees approves final DSM-5 diagnostic criteria

Post #213 Shortlink: http://wp.me/pKrrB-2xF

See also Post #212 for APA News Release (12.01.12) and Message from APA President, Dilip Jeste, M.D.

Additional media coverage and commentary will be added to the top of this post as it comes to my attention.

Updates to Media coverage

Huffington Post blog

Dilip V. Jeste, M.D.
President of the American Psychiatric Association

The New DSM Reaches the Finish Line

Dilip V. Jeste, MD | December 11, 2012

Psychiatric Times

Bereavement and the DSM-5, One Last Time

Ronald W. Pies, MD | December 11, 2012

New York Times


A Tense Compromise on Defining Disorders

Benedict Carey | December 10, 2012


Worried about work? You may need therapy: Psychiatric “bible” may classify more chronic worriers as mentally ill

Sharon Kirkey | Postmedia News |December 9, 2012

LA Times

Changes to the psychiatrists’ bible, DSM: Some reactions

Rosie Mestel | December 9, 2012


Redefining Mental Illness

Elements Behavioral Health

Binge Eating to Be Added to Mental Disorders Manual

December 8, 2012

With contribution from Sharon Kirkey


Psychiatrists To Take New Approach In Bereavement

Audio of interview with Jerome Wakefield plus transcript

December 5, 2012

New Scientist

Psychiatry is failing those with personality disorders

December 5, 2012

Psychiatric Times

APA Approves DSM-5: Final Stages Under Way

By Laurie Martin, Web Editor | December 6, 2012


The New Temper Tantrum Disorder

Will the new diagnostic manual for psychiatrists go too far in labeling kids dysfunctional?

David Dobbs| December 7, 2012

It won’t be published until May, but the American Psychiatric Association’s Diagnostic Statistical Manual, Fifth Edition, or DSM-5—an updating of the field’s highly influential and pleasingly profitable handbook—is already in deep trouble. Every decade or so, DSM publishes a major edition, and often the changes stir controversy. But the alterations the APA announced for DSM-5 this week sparked unusually ferocious attacks from critics, many of them highly prominent psychiatrists. They say the manual fails to check a clear trend toward overdiagnosis and overmedication—and that a few new or expanded diagnoses defy both common sense and empirical evidence. This medicine is not going down well…

British Psychological Society (BPS)

DSM5 approved but controversy continues

NHS Choices

Asperger’s not in DSM-5 mental health manual

Psychology Today Blogs

The People’s Professor

Psychology 360: A brain-behavior buffet, heavy to lite, A to Z by Frank Farley, Ph.D.

Reboot Diagnosis: DSM-5 Goes Live, Nascent Movement Arises

A new open global movement emerges to re-think and re-design diagnosis

Published on December 3, 2012 by Frank Farley, Ph.D. in The People’s Professor

…Our Committee’s strategy at this point is to reboot the whole program of diagnosis, to re-examine the very fundaments of the concept of diagnosis, and to assess what might be involved in creating an alternative approach to those presently available, creating a blueprint, if you will.

Any new or evolved approach would have to meet, in my view, more rigorous scientific criteria, responding to what I call “The Seven Sins of Psychiatric/Psychological science,” (Farley, 2012), incorporate the cultural/social/relationship/humanistic side of our lives, and involve all the principal disciplinary and professional stakeholders in the U.S and internationally. Given the relentless criticisms of the DSM over several decades and the failure to take some of these serious criticisms into account, our Committee (which now consists of myself and Jon Raskin as co-chairs, and members Dean Brent Robbins, Donna Rockwell, Krishna Kumar, Sarah Kamens, and student consultant Erinn Chalene Cosby) has decided to convene with international collaboration an International Ongoing/Online Summit on Diagnosis (or similar title). Among other things we anticipate bringing together scholars and practioners globally and from across the various fields involved in diagnosis to address the Olympian task of an improved approach or approaches to what we have now. We feel the psychological health and well-being of every distressed individual requires a valid and humane approach to diagnosis, and the Zeitgeist is ready…

Medscape Medical News > Psychiatry

Experts React to DSM-5 Approval

Deborah Brauser | December 3, 2012

Experts and organizations are weighing in on this weekend’s decision by the American Psychiatric Association (APA) Board of Trustees to approve the final diagnostic criteria for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)…

Press Connects

Psychiatrists to make vast changes to diagnosis manual

CBS News

Asperger’s syndrome dropped from American Psychiatric Association manual

CBS/AP/ December 3, 2012, 10:38 AM


What Effect Will Changes To The DSM-5 Have On People With (And Without) Mental Health Issues?

Alice G. Walton, Contributor | December 3, 2012

Family Practice News, Practice Trends

APA Approves Final DSM-5 Criteria

Mary Ellen Schneider | Family Practice News Digital Network | December 3,  2012


Psychiatric Group Approves New ASD Category

Autism & Asperger

Lee Wilkinson | December 3, 2012

Science Insider

Text of Divisive Psychiatric Manual Finalized

Greg Miller | December 3, 2012

Health News Review

Critic calls American Psychiatric Assoc. approval of DSM-V “a sad day for psychiatry”

Posted by Gary Schwitzer in Disease mongering, Evidence-based medicine | December 03, 2012

Psychology Today

Side Effects
From quirky to serious, trends in psychology and psychiatry

Christopher Lane, Ph.D. | December 2, 2012

A Disaster for Childhood Diagnoses

The next edition of the diagnostic manual will make a bad situation worse

The Board of Trustees of the American Psychiatric Association tried yesterday to project confidence in the next edition of its problem-plagued manual, assuring Americans that radical changes to the DSM “passed” all necessary hurdles and represented a “major milestone” for American psychiatry.

But DSM-5 is now certain to include highly controversial changes, including approval of Attenuated Psychosis Syndrome and Disruptive Mood Dysregulation Disorder—proposals that sparked widespread concern and skepticism when first circulated…

Medscape Medical News > Psychiatry

DSM-5 Gets APA’s Official Stamp of Approval

Caroline Cassels | December 2, 2012

The final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been approved by the leadership of the American Psychiatric Association (APA).

In an official communiqué released December 1 at 3:31 pm Eastern Time, the APA announced that its Board of Trustees approved the manual’s proposed criterial…


A relational view of DSM V: a care-rationing document?

Claudia M Gold | December 2, 2012

Because DSM V the newest version of the Diagnostic and Statistical manual, sometimes referred to as the “bible of psychiatry” set to come out in May 2013, makes no mention of relationships, the relational perspective is that it is a flawed instrument. The whole discussion about what categories should and should not be included is off the mark. Nonetheless, as it currently dictates who will and who will not receive treatment, it is a force to be reckoned with…

Psychology Today Blogs

DSM5 in Distress

DSM 5 Is Guide Not Bible- Ignore Its Ten Worst Changes: APA approval of DSM-5 is a sad day for psychiatry.

Allen J Frances MD | December 2, 2012

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

Brief background. DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal- to produce a paradigm shift in psychiatry. Excessive ambition combined with disorganized execution led inevitably to many ill conceived and risky proposals.

These were vigorously opposed. More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM 5 has neither been able to self correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis. Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably ‘psychosis risk’, mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, ‘hebephilia’, cumbersome personality ratings, and sharply lowered thresholds for many existing disorders). But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below.

The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good. Yesterday’s APA approval makes it likely that DSM 5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

The APA’s deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller. When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control. The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA’s projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation.

This is no way to prepare or to approve a diagnostic system. Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM 5’s ten most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM 5 decisions.

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM’s teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and ‘behavioral addictions’ will soon be mislabeled as psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill.

Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession. But we have to know our limits and stay within them.

DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm! That’s why this is such a sad moment.

UK Guardian

Asperger’s syndrome dropped from psychiatrists’ handbook the DSM

December 3, 2012


DSM-5, latest revision of Diagnostic and Statistical Manual, merges Asperger’s with autism and widens dyslexia category

Asperger’s syndrome is to be dropped from the psychiatrists’ Diagnostic and Statistical Manual (DSM) of Mental Disorders, the American publication that is one of the most influential references for the profession around the world.

The term “Asperger’s disorder” will not appear in the DSM-5, the latest revision of the manual, and instead its symptoms will come under the newly added “autism spectrum disorder”, which is already used widely. That umbrella diagnosis will include children with severe autism, who often do not talk or interact, as well as those with milder forms…

The Australian

Parents fear loss of autism funding

Dan Box | December 3, 2012

THE diagnosis of Asperger’s syndrome is being dropped from the world-leading US medical manual of psychiatric conditions, in a decision that could affect the support and funding available to thousands of Australian families.

The decision is among the first major revisions to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders since 1994…

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Media coverage

Huffington Post

DSM-5: Psychiatrists OK Vast Changes To Diagnosis Manual

Lindsey Tanner | December 1, 2012

CHICAGO — For the first time in almost two decades the nation’s psychiatrists are changing the guidebook they use to diagnose mental disorders. Among the most controversial proposed changes: Dropping certain familiar terms like Asperger’s disorder and dyslexia and calling frequent, severe temper tantrums a mental illness.

The board of trustees for the American Psychiatric Association voted Saturday in suburban Washington, D.C., on scores of revisions that have been in the works for several years. Details will come next May when the group’s fifth diagnostic manual is published.

The trustees made the final decision on what proposals made the cut; recommendations came from experts in several task force groups assigned to evaluate different mental illnesses…

MedPage Today

DSM-5 Wins APA Board Approval

John Gever, Senior Editor | December 1, 2012

The American Psychiatric Association’s board of trustees has approved the fifth edition of its influential diagnostic manual, dubbed DSM-5, the group announced Saturday.

The board vote is the last step before the manual is formally released at the APA’s annual meeting next May. The association’s Diagnostic and Statistical Manual of Mental Disorders was last revised in 1994; that edition is known colloquially as DSM-IV…

Dyslexia is out of DSM-5: Psychiatrists voted Saturday, Dec. 1, 2012

Tina Burgess | December 1, 2012

On Saturday, Dec. 1, 2012, the board of trustees of the American Psychiatric Association voted in Washington, D.C., that the term “dyslexia” will be eliminated from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

According to Saturday’s The Seattle Times report, “Board members were tightlipped about the update, but its impact will be huge, affecting millions of children and adults worldwide.”

Eliminating the term “dyslexia” from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has major implications for students with dyslexia…


Psychiatric association approves changes to diagnostic manualCNN International

Miriam Falco, CNN Medical Managing Editor | December 2, 2012

(CNN) — Starting next year, the process of diagnosing autism may see drastic changes following the revision of the official guide to classifying psychiatric illnesses.

After years of reviewing and refining criteria used by psychiatrists and other experts to diagnose mental health disorders, the American Psychiatric Association board of trustees on Saturday approved major changes to the manual, better known as DSM-5…

Dallas Morning News

Asperger’s to be removed from revised edition of American Psychiatric Association’s diagnostic manual

Associated Press The Dallas Morning News

Published: 02 December 2012 12:59 AM

CHICAGO — The now familiar term “Asperger’s disorder” is being dropped. And abnormally bad and frequent temper tantrums will be given a scientific-sounding diagnosis called DMDD. But “dyslexia” and other learning disorders remain.

The revisions come in the first major rewrite in nearly 20 years of the diagnostic guide used by the nation’s psychiatrists. Changes were approved Saturday.

Full details of all the revisions will come next May when the American Psychiatric Association’s new diagnostic manual is published, but the impact will be huge, affecting millions of children and adults worldwide. The manual also is important for the insurance industry in deciding what treatment to pay for, and it helps schools decide how to allot special education….

Wall Street Journal


Psychiatric Association’s Diagnosis Revisions Seen Upending Evaluations

Melinda Beck | December 1, 2012

Asperger’s syndrome is out and hoarding is in, and starting next year, psychiatrists may diagnose some children with a new “disruptive mood dysregulation disorder” if they have severe tantrums three or more times a week for more than a year.

After more than a decade of discussion and often heated debate, the Board of Trustees of the American Psychiatric Association voted Saturday in Arlington, Va., to approve the fifth edition of the group’s “Diagnostic and Statistical Manual for Mental Disorders” or DSM-5, the official guide to classifying psychiatric illnesses.

The changes – the first major revisions since 1994 — could…

Exclusive subscriber content – sub required to view full commentary.

USA Today

Psychiatrists to make vast changes to diagnosis manual

Sharon Jayson | December 2, 212

Manual also is important for the health insurance industry in deciding what treatments to cover.

7:58 PM EST December 1. 2012 – Asperger’s is out, but binge eating and hoarding are in as official mental disorders in the latest version of the diagnostic bible published by the American Psychiatric Association, following a vote Saturday by that group’s board…

Bloomberg Businessweek – News from Business

Psychiatrists Redefine Disorders Including Autism

Elizabeth Lopatto | December 2, 2012

The vote yesterday by the American Psychiatric Association was alternately called “a disaster” by Allen Frances, who led work on the previous version, and a “conservative document” by David Kupfer, who led the panel that presented the latest edition…

Detroit Free Press

Psychiatric group changing mental illness diagnoses

Lyndsey Tanner | December 2, 2012

The board of trustees for the American Psychiatric Association voted Saturday in suburban Washington, D.C., on scores of revisions that have been in the works for several years. Details will come in May, when the group’s fifth diagnostic manual is published…

Decoded Science

Diagnostic and Statistical Manual V: Small Changes with Big Implications

Gina Putt | December 1, 2012

The American Psychiatric Association’s timeline calls for the ”Final Revisions by the APA Task Force; Final Approval by APA Board of Trustees; Submission to American Psychiatric Publishing, Inc..” in December of 2012. This edition, the fifth, attempts to further…

NPR (blog)

Weekend Vote Will Bring Controversial Changes To Psychiatrists’ Bible

Alix Spiegel | ‎November 30, 2012‎

…The APA refuses to say anything about what’s in and what’s out, and they’ve also told people associated with the DSM-5 that they shouldn’t speak specifically, so it’s very hard to know. But some of the changes that were published last year on the APA website…

From Ben Carey, NYT, November 26

Thinking Clearly About Personality Disorders

Benedict Carey | November 26, 2012 | 355 Comments

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all…

Clinical Psychiatry News

Neuroticism and the DSM-5: What Lies Ahead?


By: MICHAEL BRODSKY, M.D., Clinical Psychiatry News Digital Network

If substantive changes to the DSM-5 framework do not occur before publication, clinicians will be called upon to evaluate personality using dimensional measures in addition to the personality diagnostic categories familiar to psychiatrists from the DSM-IV.

In this article, I want to consider the personality dimension of neuroticism, a construct with a long tradition of research and considerable evidence of both internal and external validity (Am. Psychol. 2009;64:241-56). Recent epidemiologic findings suggest that scores along this dimension may carry important clinical implications for mental and physical health…

My Debate With The DSM 5 Chair: More Translations From ‘Newspeak’ by Allen Frances

My Debate With The DSM 5 Chair: More Translations From ‘Newspeak’ by Allen Frances, M.D.

Post #186 Shortlink: http://wp.me/pKrrB-2iI

Allen Frances, M.D. is professor emeritus at Duke University and chaired the task force that had oversight of the development of DSM-IV.

My Debate With The DSM 5 Chair
More Translations From ‘Newspeak’

Allen Frances M.D. | June 25, 2012

Recently, I voiced my concerns about DSM 5 in a Medscape interview with Dr Stephen Strakowski. DSM-5 Task Force Chair David Kupfer then entered the debate and provided his defense.

Here is my reply to Dr Kupfer:

I think ‘Newspeak’ is the best way to characterize the APA defense of DSM 5. For those who haven’t read George Orwell’s ‘1984’ lately, ‘Newspeak’ was his term for the kind of bureaucratic upside-down language that attempts to turn night into day. The idea is that if you say something enough times, the repetition will magically make it so.

Let’s do a quick back-translation from APA ‘newspeak’ to DSM 5 reality.

APA Newspeak: DSM 5 has been open and “transparent to an unprecedented degree.”

DSM 5 Reality: APA forced work group members to sign confidentiality agreements; has kept its ‘scientific’ review committee report secret; tries to censor the internet using bullying threats of trademark litigation; keeps secret the content of public input; and has not, as promised, provided more complete data sets from its failed field testing.

APA Newspeak: DSM 5 has been an “inclusive” process.

DSM 5 Reality: APA has rejected the input of 51 mental health associations requesting an open and independent scientific review of the controversial DSM 5 proposals; has not responded to highly critical editorials in the Lancet, New England Journal, New York Times, and many other publications; has ignored the unanimous opposition by the leading researchers in the field to its unusable personality disorder section; has ignored the opposition of sexual disorder researchers and forensic experts to its forensically dangerous paraphilia section; has brushed off outrage by consumer groups representing the bereaved and the autistic; has not made any changes in DSM 5 that can be associated with outside input- professional or public; and is unresponsive even to its own APA members, dozens of whom have told me they can’t get a straight (or any) answers from a staff whose salaries come from their dues.

APA Newspeak: “The stakes are far reaching: the first full revision since 1994 of the DSM, a document that influences the lives of millions of people around the world.”

DSM 5 Reality: APA quietly cancelled its own planned Stage 2 of field testing. Stage 2 was to provide quality control with much needed editing and retesting to demonstrate improved reliability. Canceling quality control was a crucial mistake and was done for one reason only-money. Because Stage 1 of the field trial was completed 18 months late, DSM 5 was running out of time in meeting its arbitrarily imposed publishing deadline. Given the choice of striving for quality or cashing in on publishing profits, APA went for the cash. Definitely dispiriting, but not surprising. APA is in deficit, has a budget that is totally dependent on the huge publishing profits from its DSM monopoly; and has wasted an absolutely remarkable $25 million in producing DSM 5 (DSM IV cost only one fifth as much). The simple reality is that APA is rushing a poor quality and unreliable DSM 5 to press purely for financial reasons and totally heedless of the detrimental effect this will have on “the lives of millions of people around the world.

APA Newspeak: “Charges that DSM-5 will lower diagnostic thresholds and lead to a higher prevalence of mental disorders are patently wrong. Results from our field trials, secondary data analyses, and other studies indicate that there will be essentially no change in the overall rates of disorders once DSM-5 is in use.”

DSM 5 Reality: DSM 5 made a fatal and unaccountable error in its field testing- it failed to measure the impact of any of its changes on rates and APA therefore has no meaningful data on this most important question. With the exception of autism, all of the suggested DSM 5 changes will definitely raise rates, some dramatically. Adding Binge Eating Disorder by itself would add more than ten million new ‘patients’; adding Disruptive Mood Dysregulation Disorder and Minor Neurocognitive Disorder would add millions; as would removing the bereavement exclusion to MDD and lowering thresholds for ADHD and GAD.

Read the full Medscape exchange for more Newspeak from Dr Kupfer, but you get the idea. It is not at all clear to me if APA talks Newspeak cynically, because of naivete, or because Newspeak is the language its expensive public relations consultants put in its mouth.

It doesn’t really matter why. Newspeak is devastating- not because anyone outside DSM 5 believes it (DSM 5 defenses are too transparently out of touch with reality to fool outsiders), but because APA may believe its own Newspeak or at least acts as if it does. Reflexive Newspeak, substituting for insight, has prevented DSM 5 from the serious self correction that would have saved it from itself. Bob Spitzer presciently predicted five years ago that a secretive, closed, defensive DSM 5 process would lead inevitably to this failed DSM 5 product.

Medscape has opened a physician-only discussion on the proposed DSM revision. If you are an MD and want to add your thoughts, you can do this at:


If you are a non-MD health care worker with an interest in psychiatric diagnosis, please add your thoughts at:


The public has a big stake in the outcome and can participate by commenting below. DSM 5 is very close to being set in stone. It may or may not do any good to speak up now, but this is a last chance for people to have their say.

Ed: Free registration is required for access to most areas of Medscape Medical News

Patient submissions to third and final DSM-5 stakeholder review

Patient submissions to third and final DSM-5 stakeholder review

Post #182 Shortlink: http://wp.me/pKrrB-2f5

This third and final stakeholder review is scheduled to close on Friday. If an extension is announced I will update.

As with the two previous draft reviews, in 2010 and 2011, I am collating copies of submissions on these pages.

If you have submitted to the Somatic Symptom Disorder proposals or are a professional, professional body or advocacy organization that has submitted a general response which includes reference to the  Somatic Symptom Disorder proposals I would be pleased to receive a copy for publication on this site. Submissions will be published subject to review and posted in PDF format if more than a few pages long.

The most recent submission received is from “US patient 1”. This is a detailed response which I am publishing in both text and PDF format. (Note that as far as I can see submissions can only be uploaded to the DSM-5 Development site using the RT or html text editor and not as file attachments.)

Submission from US patient 1 to J 00 SSD and J 02 Conversion Disorder (FNSD)

Full text in PDF:    DSM-5 submission

To: DSM-5 Task Force, Somatic Symptom Disorders Work Group
From: _______
Re: Response on the Proposals for Somatic Symptom Disorder and Conversion Disorder
Date: June 12, 2012

The DSM-5 Task Force has thus far failed to address the conceptual and practical problems inherent in DSM-IV somatoform disease constructs. Specifically, its proposals for Somatic Symptom Disorder and Conversion Disorder are actually more flawed than their equivalents in DSM-IV. The criteria for these two diagnoses rely excessively upon purely subjective judgments by clinicians and on the extent of a clinician’s awareness of known diseases, and lack the specificity required of valid diagnostic constructs.

To understand just how strongly subjectivity of clinical interpretation can impact diagnostic outcome when using somatoform disorder criteria on a disease with unknown etiology, it is instructive to consider in some detail Johnson et al’s “Assessing Somatization Disorder in Chronic Fatigue Syndrome”1, a study on the reliability of DSM-III-R somatization disorder (SD) criteria and related instruments when applied to patients with chronic fatigue syndrome (CFS). As the DSM-III-R SD diagnostic construct was less subjective and had greater specificity in terms of symptom presentation than the proposed SSD criteria, a careful examination of its flaws, as demonstrated by this study, offers a sobering perspective on real world application of SSD criteria.

CFS is a somatic disease of unestablished etiology; the United States Centers for Disease Control has stated that “Research shows that CFS is not a form of psychiatric illness” and that an essential criterion for its diagnosis is “severe chronic fatigue of 6 months or longer that is not explained by any medical or psychiatric diagnosis”. Nevertheless, in spite of such evidence, an opinion persists in the medical community that CFS is in some way a psychosomatic illness, an opinion which can easily influence clinicians in their diagnoses of patients who satisfy CFS criteria. Thus, as Johnson et al noted: “Whether or not symptoms of CFS are considered medically caused will strongly affect the incidence of SD within the CFS population…If the examiner recognizes that the patient’s CFS symptoms indicate a physical illness, the diagnosis of SD may not be made. Conversely, if the examiner does not consider CFS a medical illness, the patient’s symptom endorsement may lead to the diagnosis of SD.”

To begin with, Johnson et al discussed the problems with the DSM-III-R criteria for somatization disorder:

“According to DSM-III-R .. the diagnosis of somatization disorder (SD) requires a person to present with at least 13 symptoms for which no significant organic pathology can be found. The symptoms must have caused the person to take medication, to see a physician, or to have altered her/his lifestyle. The disorder begins before the age of 30 and has a chronic but fluctuating course. However, the diagnosis of SD is extremely problematic in terms of its validity because it involves a series of judgments that can be arbitrary and subjective […] Specifically, the interviewer must decide if the symptom reported is attributable to an identifiable medical illness. Although such judgments are extremely difficult to make uniformly, the influence of bias introduced by the interviewer’s orientation on the prevalence of SD has not been adequately addressed.”

They noted the high variation between the estimates of SD prevalence in CFS patient cohorts reported by previous studies and concluded that it was “in itself indicative of the problem in defining SD”. They further pointed out that “The difficulty in distinguishing among somatic symptoms that are psychiatric vs. organic in origin can result in overdiagnosis of SD in medical illness, particularly chronic illness”, as they had observed in several studies by other authors on somatization in CFS.

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