DSM-5 goes to press with ‘Somatic Symptom Disorder’ amid widespread professional and consumer concern

February 6, 2013 by

DSM-5 goes to press with ‘Somatic Symptom Disorder’ amid widespread professional and consumer concern

Post #224 Shortlink: http://wp.me/pKrrB-2EV

Update: On February 8, David J. Kupfer, MD, Chair, DSM-5 Task Force, published in defence of the ‘Somatic Symptom Disorder’ category on Huffington Post:

Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care

Last week, the American Psychiatric Association sent the next edition of its Diagnostic and Statistical Manual of Mental Disorders to the publishers.

When DSM-5 is released in May, it will introduce a new ‘catch-all’ diagnosis that could capture many thousands more patients under a mental disorder label.

Today, on Saving Normal at Psychology Today, Allen Frances, MD, who chaired the DSM-IV Task Force, publishes the third in a series of commentaries voicing considerable concern for all illness groups for the implications of an additional diagnosis of ‘Somatic Symptom Disorder.’

Why Did DSM 5 Botch Somatic Symptom Disorder?

Allen Frances writes:

“Once it is an official DSM 5 mental disorder, SSD is likely to be widely misapplied – to 1 in 6 people with cancer and heart disease and to 1 in 4 with irritable bowel syndrome and fibromyalgia…The definition of SSD is so loose it will capture 7% of healthy people (14 million in the US alone) suddenly making this pseudo diagnosis one of the most common of all ‘mental disorders’ in the general population.”

Suzy Chapman writes:

“These highly subjective, difficult to assess criteria have the potential for widespread misapplication, particularly in busy primary care settings – causing stigma to the medically ill and potentially resulting in poor medical workups, inappropriate treatment regimes and medico-legal claims against clinicians for missed diagnoses.

“Why has the Task Force and APA Board of Trustees been prepared to sign off on a definition and criteria set that lacks a body of rigorous evidence for its validity, safety and prevalence, thereby potentially putting the public at risk? And why is APA prepared to abrogate its duty of care as a professional body and expose its membership, physicians and the allied health professional end-users of its manual to the risk of potential law suits?”

From May, an additional mental health diagnosis of ‘Somatic Symptom Disorder’ (SSD) can be applied whether patients have diagnosed medical diseases like diabetes, angina, cancer or multiple sclerosis, chronic illnesses like IBS, fibromyalgia, chronic fatigue syndrome or chronic pain disorders, or unexplained conditions that have so far presented with bodily symptoms of unclear etiology.

A person will meet the criteria for ‘Somatic Symptom Disorder’ by reporting just one or more bodily symptoms that are distressing or disruptive to daily life, that have persisted for at least six months, and having just one of the following three responses:

1) disproportionate, persistent thoughts about the seriousness of their symptoms;
2) persistently high level of anxiety about their health or symptoms;
3) devoting excessive time and energy to symptoms or health concerns.

In the DSM-5 field trials, 15% of the ‘diagnosed illness’ study group (the trials looked at patients with either cancer or coronary heart disease) met the criteria for an additional mental health diagnosis of SSD.

26% of patients who comprised the irritable bowel syndrome or fibromyalgia study group were coded for SSD.

A disturbingly high 7% of the ‘healthy’ control group were also caught by these overly-inclusive criteria.

+++

Psychiatric creep

As the criteria stand, this new disorder will potentially result in a ‘bolt-on’ mental health diagnosis being applied to all chronic illnesses and medical conditions if the clinician decides the patient’s response to distressing symptoms is ‘excessive’ or their coping strategies are ‘maladaptive,’ or that they are ‘catastrophising’ or displaying ‘fear avoidance.’ Or if the practitioner feels the patient is spending too much time on the internet researching data, symptoms and treatments, or that their lives have become ‘dominated’ by ‘illness worries,’ they may be vulnerable to an additional diagnosis of SSD.

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

There is no substantial body of research to support the validity, reliability or safety of the ‘Somatic Symptom Disorder’ diagnosis.

During the second public review of draft criteria for DSM-5, the ‘Somatic Symptom Disorder’ section received more submissions from advocacy organizations, patients, and professionals than almost any other disorder category. But rather than tighten up the criteria or subject the entire disorder section to independent scientific review, the SSD Work Group’s response has been to lower the threshold even further – potentially pulling even more patients under a mental disorder label.

The ‘Somatic Symptom Disorder’ Work Group has rejected eleventh hour calls from professionals and patients to review its criteria before going to print.

APA says there will be opportunities to reassess and revise DSM-5‘s new disorders, post publication, and that it intends to start work on a ‘DSM-5.1’ release. But patient groups, advocates and professionals are not reassured by a ‘publish first – patch later’ approach to science.

Read Parts One and Two, here:

Part One: Mislabeling Medical Illness As Mental Disorder | Allen Frances, December 8, 2012

Part Two: Bad News DSM-5 Refuses To Correct Somatic Symptom Disorder | Allen Frances, January 16, 2013

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Notes for media, websites, bloggers:

1. The next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be published by American Psychiatric Publishing Inc. in May 2013. It will be known as ‘DSM-5 ‘ and has been under development since 1999.
http://www.dsm5.org/Pages/Default.aspx
http://www.dsm5.org/Documents/DSM%205%20development%20factsheet%201-16-13.pdf

2. The American Psychiatric Association (APA) has spent $25 million on the development of DSM-5.

3. The Diagnostic and Statistical Manual of Mental Disorders is used by mental health and medical professionals for diagnosing and coding mental disorders. It is used by psychiatrists, psychologists, therapists, counselors, primary health care physicians, nurses, social workers, occupational and rehabilitation therapists and allied health professionals.

The DSM is also used for reimbursement and informs government, public health policy, courts and legal specialists, education, forensic science, prisons, drug regulation agencies, pharmaceutical companies and researchers. Diagnostic criteria defined within DSM determine what is considered a mental disorder and what is not, which treatments and therapies health insurers will authorise funding for, and for how long.

4. Four existing disorder categories in the DSM-IV ‘Somatoform Disorders’ section: somatization disorder [300.81], hypochondriasis [300.7], pain disorder, and undifferentiated somatoform disorder [300.82] will be eliminated and replaced with a single new category – ‘Somatic Symptom Disorder’ for DSM-5.

5. APA has held three stakeholder comment periods during which professional and public stakeholders have been invited to submit comment on the proposals for the revision of DSM-IV categories and criteria (in February-April 2010; May-June 2011; May-June 2012).

6. DSM-5 is slated for release at the American Psychiatric Association’s 166th Annual Meeting, San Francisco (May 18-22, 2013). The new manual is available for pre-order and will cost $199: http://www.psychiatry.org/dsm5

7. Allen Frances, MD, was chair of the DSM-IV Task Force and of the Department of Psychiatry at Duke University School of Medicine, Durham, NC; Dr Frances is currently professor emeritus, Duke.

8. Dr Frances blogs at DSM 5 in Distress, and Saving Normal at Psychology Today.

Mislabeling Medical Illness As Mental Disorder was published on December 8, 2012

Bad News DSM-5 Refuses To Correct Somatic Symptom Disorder was published on January 16, 2013

For additional information on ‘Somatic Symptom Disorder’:

Somatic Symptom Disorder could capture millions more under mental health diagnosis by Suzy Chapman for Dx Revision Watch, May 26, 2012

Suzy Chapman

Filed under Allen Frances, American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

ICD-11 Beta draft and Bodily Distress Disorders; Per Fink and Bodily Distress Syndrome: Parts One and Two

February 3, 2013 by

ICD-11 Beta draft and Bodily Distress Disorders; Per Fink and Bodily Distress Syndrome Parts One and Two

Post #222 Shortlink: http://wp.me/pKrrB-2Dz

Caveats: The ICD-11 Beta drafting platform is not a static document: it is a work in progress, subject to daily edits and revisions, to field test evaluation and to approval by Topic Advisory Group Managing Editors, the ICD Revision Steering Group and WHO classification experts. The current draft may differ to the information in this report.

Part One

On January 6, I posted a brief update on proposals for the revision of ICD-10’s Somatoform Disorders based on what can be seen in the public version of the ICD-11 Beta drafting platform and on a book chapter by Professor, Sir David Goldberg. [1]

Professor Goldberg chairs the working group for revision of the mental health chapter of ICD-1o-PHC, the abridged, primary care version of ICD-10.

For the revision of ICD-10’s Somatoform Disorders sections for ICD-11, a WHO Expert Working Group on Somatic Distress and Dissociative Disorders has been assembled.

Professor Francis Creed (also a member of the DSM-5 Somatic Symptom and Related Disorders Work Group) is a member of this WHO working group, which is chaired by Professor Oye Gureje.

An April 2011 announcement by Stony Brook Medical Center states that Dr Joan E. Broderick, PhD had been appointed to the WHO Expert Working Group on Somatic Distress and Dissociative Disorders and that the first meeting of the group (said to consist of 17 international behavioral health professionals) was expected to be held in June 2011, in Madrid.

WHO has not published a list of  members of this working group or any progress reports and the names and affiliations of the 14 other members are unknown, so I am unable to confirm whether Professor Per Fink is a member of the group, which reports to the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders.

ICD-11 and Bodily Distress Disorders

ICD-11 is currently scheduled for completion in 2015/16. When viewing the public version of the Beta drafting platform please bear in mind the ICD-11 Revision Caveats: that the Beta draft is a work in progress, updated daily, is incomplete, may contain errors and is subject to change; not all proposals may be approved by the ICD-11 Revision Steering Committee or WHO classification experts, or retained following analysis of ICD-11 and ICD-11-PHC field trials.

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

Foundation View: http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1472866636
Linearization View: http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1472866636

As the ICD-11 Beta drafting platform stands at the time of compiling this report, the existing ICD-10 Somatoform Disorders are proposed to be subsumed under or replaced by Bodily Distress Disorders, and Psychological and behavioural factors associated with disorders or diseases classified elsewhere.

The following proposed ICD-11 categories are listed as child categories under parent term, 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

No Definition or any other Content Model parameters have been populated for the proposed categories EC5, EC6 and EC7, which are new entities to ICD. (EC8 is a legacy category from ICD-10.)

Note that the sorting codes assigned to categories are subject to frequent change as chapters are reorganized.

From the information currently displaying in the Beta draft, it is not possible to determine:

• how ICD-11 proposes to define Bodily Distress Disorders;

• what diagnostic criteria are being proposed;

• whether diagnostic criteria would be based on a requirement for excessive or disproportionate psychological and behavioral characteristics in response to distressing somatic symptoms, such as illness anxiety, symptom focusing, catastrophising, maladaptive coping strategies, avoidance behavior or misattribution; or based on somatic symptom counts, or specific symptom clusters, or number of bodily systems affected, or a combination of these;

• how the three Severity Specifiers: Mild, Moderate and Severe would be categorized;

• how the three Severities would be assessed for within primary and secondary care;

• whether ICD-11’s proposed Bodily Distress Disorder construct is intended to mirror or incorporate DSM-5’s Somatic Symptom Disorder (SSD) construct, in line with ICD-11/DSM-5 harmonization, or

• whether it is intended to mirror or incorporate Per Fink’s Bodily Distress Syndrome (BDS) construct, or to combine elements from both;

• whether the Bodily Distress Disorder construct is proposed only to be applied to patients with distressing ‘medically unexplained somatic symptoms’ (MUS), or the so-called ‘Functional somatic syndromes’ (FSS), if the patient is considered to also meet the BDD criteria, or

• whether it is proposed to be inclusive of patients with distressing somatic symptoms in the presence of diagnosed illness and general medical conditions, if the patient is considered to also meet the criteria;

• whether the Bodily Distress Disorder construct is proposed to be inclusive of parents or caregivers perceived as encouraging maintenance of sick role behavior or over-involved.

• whether the Bodily Distress Disorder construct is proposed to be inclusive of children;

• whether it is proposed that all or selected of the following: Neurasthenia and Fatigue syndrome (F48.0), Chronic fatigue syndrome (indexed to G93.3 in ICD-10; classified in ICD-11 Beta draft as an ICD Title term in Chapter 6: Diseases of the nervous system), IBS (K58), and Fibromyalgia (M79.7) should be reclassified under Bodily Distress Disorders;

• whether the Bodily Distress Disorder construct is proposed to subsume ICD-10’s Hypochondriacal disorder with somatic symptoms or incorporate this entity under Illness Anxiety Disorder for ICD-11.

(For ICD-11, ICD-10’s Hypochondriacal disorder [F45.2] is currently proposed to be renamed to Illness Anxiety Disorder and located underANXIETY AND FEAR-RELATED DISORDERS.)

 • what ICD-11 proposes to do with ICD-10’s Neurasthenia;

(ICD-10’s Chapter V Neurasthenia [F48.0] is no longer listed in the public version of the ICD-11 Beta draft. For ICD-11-PHC, the primary care version of ICD-11, the proposal is for the term Neurasthenia to be eliminated. Since terms used in ICD-11-PHC require corresponding terms in the main classification, the intention may be to eliminate Neurasthenia from the main version, or subsume under another term.) [2]

All that can be determined from the Beta draft is that these earlier ICD-11 Beta draft Somatoform Disorders categories appear proposed to be subsumed under or replaced with the new BDD categories, EC5, EC6 and EC7, set out 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]

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

This category is proposed for the 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.” [2]

In a future post (Part Three of this report), I shall be discussing emerging proposals for the ICD-11 construct, Bodily Distress Disorders, which may serve to fill in some of the gaps.

In the meantime, since it is unclear whether and to what extent the ICD-11 Bodily Distress Disorders category is proposed to mirror or incorporate the Bodily Distress Syndrome construct developed by Per Fink et al, Aarhus, Denmark, I am providing some material on Bodily Distress Syndrome in Part Two

Filed under Bodily Distress Disorders, Bodily distress syndrome, DSM-5 draft proposals, ICD revision process, ICD-10, ICD-11 Beta Draft, MUS, Somatic Symptom Disorder, Somatoform Disorders, WHO (World Health Organization) Tagged with , , , , , , , , ,

Brief update on DSM-5 ‘Somatic Symptom Disorder’

January 30, 2013 by

Brief update on DSM-5 ‘Somatic Symptom Disorder’

Post #221 Shortlink: http://wp.me/pKrrB-2Dd

As previously reported, all draft proposals for categories and criteria for DSM-5 were frozen on the DSM-5 Development website on June 15, 2012, immediately following the closure of the third and final stakeholder review and comment period.

Changes made to the draft after June 15, 2012 are embargoed and final disorder descriptions and criteria sets won’t be evident until DSM-5 is released, in May, this year, unless APA elects to release selected information.

The manual texts that expand on the various disorder sections and the categories that sit within them have not been made public at any stage in the development process. It is understood that for the ‘Somatic Symptom Disorders’ group, for example, the manual text that accompanies these new categories and criteria sets will run to five or six pages.

On November 15, 2012, APA removed the entire third draft from the DSM-5 Development website.

According to this APA Permissions, Licensing & Reprints page, because the most recently posted draft [the third draft that was released on May 2, 2012] has undergone revisions and is no longer current, the criteria texts have been removed from the website in order to avoid confusion or use of outdated categories and definitions. [1]

The page also states that although APA Board of Trustees approved all the proposed diagnoses [in December, 2012] there continue to be minor editorial and content changes as APA moves towards the final stages of the publication process.

Although the DSM-5 Development Timeline has “Final Revisions by the APA Task Force; Final Approval by APA Board of Trustees; Submission to American Psychiatric Publishing, Inc” scheduled for December 2012, according to my sources, the manual texts were now expected to be finalized for the publishers by end of January.

 

DSM-5 Table of Contents

As also previously reported, APA has created new pages for information and resources for DSM-5, where a number of new articles and documents are available to download. [2][3]

http://www.psychiatry.org/dsm5

Documents include a DSM-5 Table of Contents which lists the disorder sections and the category terms that sit within them.

The DSM-5 Table of Contents reveals that changes to the overall section name for  the ‘Somatic Symptom Disorders’ categories and to the category names that sit within this section have been made since closure of the third and final draft.

For the overall disorder section name, DSM-5 will now be using

‘Somatic Symptom and Related Disorders’

rather than

‘Somatic Symptom Disorders’ as per the first, second and third drafts.

For the third draft, the 6 disorders proposed to sit under this disorder section were:

Somatic Symptom Disorders (SSD)

J 00 Somatic Symptom Disorder
J 01 Illness Anxiety Disorder
J 02 Conversion Disorder (Functional Neurological Symptom Disorder)
J 03 Psychological Factors Affecting Medical Condition
J 04 Factitious Disorder
J 05 Somatic Symptom Disorder Not Elsewhere Classified

7 categories are now listed (on Page 3) of the DSM-5 Table of Contents as follows:

Somatic Symptom and Related Disorders

Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder (Functional Neurological Symptom Disorder)
Psychological Factors Affecting Other Medical Conditions
Factitious Disorder
Other Specified Somatic Symptom and Related Disorder
Unspecified Somatic Symptom and Related Disorder

Other than these revisions to the SSD disorder section name and category names, there are no other texts disclosed within the DSM-5 Table of Contents. So whatever text is included for the latter two categories, ‘Other Specified Somatic Symptom and Related Disorder’ and ‘Unspecified Somatic Symptom and Related Disorder,’ isn’t known.

Whether any revisions have been made to the disorder descriptions and criteria for the five other disorders since the third draft proposals were posted is also unknown because of the embargo on disclosure of changes to categories and criteria beyond June 15, last year.

 

SSD Work Group asked to reconsider

In December, Allen Frances, MD, who had chaired the Task Force that had oversight of the development of DSM-IV, asked the SSD Work Group, key APA Board of Trustees members and Task Force Chairs to reconsider the proposals for specifically the ‘Somatic Symptom Disorder’ category. [4]

These representations were made in response to Dr Frances’ own considerable concerns, and those of lay and professional stakeholders, for the looseness of the SSD definition and criteria set, as it had stood at the third draft, and the absence of a body of robust evidence for the validity and safety of ‘SSD’ as a construct, and data on likely prevalence rates.

Dr Frances also proffered suggestions for revisions that he considered would tighten up the criteria and reduce the potential for misapplication.

The response on behalf of the work group was that although Dr Frances’ suggestions were discussed, the work group would not be revising their recommendations. [5]

It is not known whether the concerns raised by Dr Frances in December were discussed beyond the SSD Work Group with the DSM-5 Task Force or with the APA Board of Trustees, who are responsible for approving proposals and therefore accountable for the content of the forthcoming manual.

 

ICD-11 and DSM-5

In a January 18 article for Psychiatric News, organ of the APA, Mark Moran reports:

“Kupfer [DSM-5 Task Force Chair] said the classification of disorders is largely harmonized with the World Health Organization’s International Classification of Diseases (ICD) so that the DSM criteria sets are more parallel with the proposed ICD-11. In DSM-5 both the current ICD-9-CM and the future standard ICD-10-CM codes (scheduled for 2014) are attached to the relevant disorders in the classification.” [6]

As reported in my Dx Revision Watch post of January 6, at the time of writing, current proposals in the ICD-11 Beta draft have ICD-10’s ‘Somatoform Disorders’ replaced with ‘Bodily Distress Disorders, and Psychological and behavioural factors associated with disorders or diseases classified elsewhere,’ with three, as yet undefined, Severities of ‘Bodily Distress Disorder.’ [7]

It remains to be clarified whether ICD-11’s Beta draft proposals for three Severities of ‘Bodily Distress Disorder’ to replace six ICD-10 ‘Somatoform Disorders’ proposes to mirror Per Fink’s definition and criteria for ‘Bodily Distress Syndrome’ or are more closely aligned with DSM-5‘s ‘Somatic Symptom Disorder,’ in keeping with the APA and WHO’s joint commitment to strive, where possible, for harmonization between the category names, glossary descriptions and criteria across the two systems. [8]

(I shall be addressing this issue in a future post.)

I have previously reported that for ICD-11-PHC, the abridged, Primary Health Care version of ICD-11, the proposal, last year, was for a disorder section called ‘Bodily distress disorders,’ under which would sit ‘Bodily stress [sic] syndrome.’ [9]

According to Professor, Sir David Goldberg, this category is proposed for ICD-11 Primary Health 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.” These proposals are subject to rejection or modification following ICD-11 Field Trials. [10]

DSM-5 is scheduled for release at the APA’s 166th Annual Meeting (San Francisco, May 18-22).

 

References and related reports

1] American Psychiatric Publishing Permissions, Licensing & Reprints

2] New DSM-5 webpages

3] DSM-5 Table of Contents

4] Mislabeling Medical Illness As Mental Disorder: The Eleventh DSM-5 Mistake, Psychology Today, DSM5 in Distress, Allen Frances, MD, December 8, 2012

5] Bad News: DSM 5 Refuses to Correct Somatic Symptom Disorder, Psychology Today, DSM5 in Distress, Allen Frances, MD, January 16, 2012

6] Continuity and Changes Mark New Text of DSM-5, Psychiatric News, Volume 48, Number 2, January 18, 2013: pp. 1-6 

7] ICD-11 Beta Draft Public Version: Bodily Distress Disorders
http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fwho.int%2ficd%23F45

8] Fink P, Schröder A. One single diagnosis, bodily distress syndrome, succeeded to capture ten diagnostic categories of functional somatic syndromes and somatoform disorders. J Psychosom Res 2010;68:415-26
http://www.ncbi.nlm.nih.gov/pubmed/20403500

9] Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS. Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. Fam Pract 2012
http://www.ncbi.nlm.nih.gov/pubmed/22843638

10] Goldberg DP. Comparison Between ICD and DSM Diagnostic Systems for Mental Disorders. In: Sorel E, (Ed.) 21st Century Global Mental Health. Jones & Bartlett Learning, 2012: 37-53 [Free PDF Sample Chapter 2]

11] Somatic Symptom Disorder could capture millions more under mental health diagnosis, Suzy Chapman for Dx Revision Watch, May 26, 2012

Filed under Allen Frances, American Psychiatric Association (APA), Bodily Distress Disorders, Bodily stress syndrome, Criticism of DSM-V, DSM-5, DSM-5, DSM-5 draft proposals, DSM-5 in the media, Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

DSM-5 rejects call for urgent reconsideration of new “Somatic Symptom Disorder” category

January 17, 2013 by

DSM-5 rejects call from lead psychiatrist for DSM-IV Task Force for urgent reconsideration of new “Somatic Symptom Disorder” category 

Post #219 Shortlink: http://wp.me/pKrrB-2C0

Today, Allen Frances, M.D., publishes a follow-up to our December 8 commentary in which we set out the implications for all chronic illness patient populations of misdiagnosis with “Somatic Symptom Disorder (SSD)” or misapplication of an additional diagnosis of “SSD.”

In the second of three commentaries, Dr Frances reports on the outcome of his representations to the DSM-5 Somatic Symptom Disorder Work Group, key APA Board of Trustees office holders and DSM-5’s Task Force chair and vice-chair, for urgent reconsideration of this new “catch-all” mental health disorder.

The texts for DSM-5 are expected to be finalized for the publishers by the end of this month.

Dr Frances’ first commentary on SSD is approaching 20,000 views and has received over 300 comments on Psychology Today, alone. It is also published at Huffington Post and at Education Update and widely circulated on other platforms.

There has been an overwhelming response to our concerns with comments pouring in from patients with diverse chronic illnesses and medical conditions including Ehlers-Danlos Syndrome, Interstitial Cystitis, Behcet’s disease, Endometriosis, Lupus, Hashimotos thyroid disorder, Hughes Syndrome, Pancreatitis and Chronic Lyme disease –patients whose symptoms had been dismissed for years before finally receiving a diagnosis or who are still struggling to obtain a diagnosis, many of whom had been mislabelled with a somatoform disorder.

We’ve also received many emails from patients and international patient organizations.

Please circulate this follow-up commentary. I am particularly keen to reach platforms for patients with common chronic diseases and conditions – cancer, heart disease, diabetes, COPD, MS, RA, chronic pain; also Lyme disease, chemical injury and rare diseases, IBS and Fibromyalgia, ME and CFS.

Allen Frances, M.D., was 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.

Psychology Today

DSM5 in Distress

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

Published on January 16, 2013 by Allen J. Frances, M.D., in DSM5 in Distress

Bad News: DSM 5 Refuses To Correct Somatic Symptom Disorder
Medical Illness Will Be Mislabeled Mental Disorder

“Many of you will have read a previous blog prepared by Suzy Chapman and me that contained alarming information about the new DSM 5 diagnosis ‘Somatic Symptom Disorder.’

“SSD is defined so over inclusively by DSM 5 that it will mislabel 1 in 6 people with cancer and heart disease; 1 in 4 with irritable bowel and fibromyalgia; and 1 in 14 who are not even medically ill.

“I hoped to be able to influence the DSM 5 work group to correct this in 2 ways: 1) by suggesting improvements in the wording of the SSD criteria set that would reduce mislabeling; and 2) by letting them know how much opposition they would face from concerned professionals and an outraged public if DSM 5 failed to slam on the brakes while there was still time…”

Read on here:

Bad News: DSM 5 Refuses To Correct Somatic Symptom Disorder
Medical Illness Will Be Mislabeled Mental Disorder

 

The most recent proposals for new category “J 00 Somatic Symptom Disorder”

IASP and the Classification of Pain in ICD-11  Prof. Dr. Winfried Rief, University of Marburg, Germany

Slide 9

Ed: Note that the requirement for “at least two from the B type criteria” was reduced to “at least one from the B type criteria” for the third iteration of draft proposals. This lowering of the threshold is presumably in order to accommodate the merging of the previously proposed “Simple Somatic Symptom Disorder” category into the “Complex Somatic Symptom Disorder” category, a conflation now proposed to be renamed to “Somatic Symptom Disorder,” also the disorder section name. A revised “Rationale/Validity” PDF document was not issued for the third and final draft. A brief, revised “Rationale” text was published on a Tab Page for the Somatic Symptom Disorder proposal and criteria but is no longer accessible.

Proposals, criteria and rationales, as posted for the third draft in May 2012, were removed from the DSM-5 Development website on November 15, 2012 and placed behind a non public log in. Criteria as they had stood for the third draft can no longer be viewed but are set out on Slide 9 in this presentation, which note, does not include three, optional Severity Specifiers that were included with the third draft criteria.

 

Related material

Mislabeling Medical Illness As Mental Disorder: The Eleventh DSM-5 Mistake, Psychology Today, DSM5 in Distress, Allen Frances, MD, December 8, 2012

Somatic Symptom Disorder could capture millions more under mental health diagnosis, Suzy Chapman

Submission to Somatic Symptom Disorder Work Group in response to third draft proposals, Suzy Chapman

Additional commentary

Oak Park Behavioral Medicine, Mind Your Body blog

Moving in the Wrong Direction

Dr Tiffany Taft, Ph.D., Northwestern University, December 13, 2012

IBS Impact IBS Impact blog

Proposed DSM-5 Criteria May Unfairly Label Physical Conditions as Psychological Disorders

Filed under Allen Frances, American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

Update on ICD-11 Beta draft: Bodily Distress Disorder

January 6, 2013 by

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:

http://www.rcpsych.ac.uk/pdf/Garralda%20E.pdf

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

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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:
http://apps.who.int/classifications/icd11/browse/Help/Get/caveat/en

4] The Bodily Distress Disorders section of the ICD-11 Beta draft Chapter 5 can be found here:
http://apps.who.int/classifications/icd11/browse/f/en#/http%3a%2f%2fwho.int%2ficd%23F45
http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fwho.int%2ficd%23F45

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.

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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.)

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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.

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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:

http://apps.who.int/classifications/icd11/browse/f/en#http%3a%2f%2fwho.int%2ficd%23G93.3

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:

https://dxrevisionwatch.com/wp-content/uploads/2010/06/change-history-gj92-cfs.png

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.

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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:

https://dxrevisionwatch.com/wp-content/uploads/2010/05/2icatgj92cfsdef.png

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.

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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:
http://apps.who.int/classifications/apps/icd/icatfiles/iCAT_Glossary.html

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Related material:

http://www.rcpsych.ac.uk/pdf/8%20Ash%20IC2012.pdf

Presentation slides: Medically Unexplained Symptoms pages

Dr Graham Ash, Lancashire Care NHS Foundation Trust

Website pages featured in the slide presentation:

Medically Unexplained Symptoms

http://www.rcpsych.ac.uk/expertadvice/improvingphysicalandmh/aboutthissite.aspx

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

Filed under American Psychiatric Association (APA), Bodily Distress Disorders, Bodily stress syndrome, Chronic fatigue syndrome, DSM-5 draft proposals, Francis Creed, ICD-11 Beta Draft, Myalgic encephalomyelitis, Postviral fatigue syndrome, Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

11th hour call: “Mislabeling Medical Illness As Mental Disorder” by Allen J. Frances, MD.

December 24, 2012 by

11th hour call: “Mislabeling Medical Illness As Mental Disorder” by Allen J. Frances, MD.

Post #217 Shortlink: http://wp.me/pKrrB-2AL

Image Copyright Dx Revision Watch 2012On December 8, Allen J. Frances, MD, blogged at Psychology Today on our shared concerns for the new DSM-5 category – Somatic Symptom Disorder. Dr Frances was 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, Duke.

One in six people suffering from cancer, heart and other serious diseases risks being saddled with a psychiatric diagnosis if they are considered to be “excessively” worried about their illness or spending more time on the internet researching their symptoms than the American Psychiatric Association (APA) thinks good for them.

But many illness groups – particularly the so-called “functional somatic syndromes” – stand to be captured by these new criteria and assigned an additional mental health diagnosis, or placed at risk of misdiagnosis.

The DSM-5 manual texts are still being finalized and the Somatic Symptom Disorder Work Group has been asked to reconsider its criteria and tighten them up before the next edition of DSM is sent to the publishers.

Please demonstrate to the APA and the Somatic Symptom Disorder Work Group the level of concern amongst clinicians and allied health professionals, patients, caregivers and advocacy organizations by visiting Dr Frances’ blog post and leaving a comment. You can read the commentary at the link, below.

If you share our concerns that these catch-all criteria will see thousands more patients tagged with a mental health label please forward the link to your colleagues and contacts and post on Twitter, blogs and social media platforms.

Thank you,

Suzy Chapman for Dx Revision Watch

Mislabeling Medical Illness As Mental Disorder: The Eleventh DSM-5 Mistake

Psychology Today, DSM5 in Distress, Allen Frances, MD, December 8, 2012

Additional commentary

Oak Park Behavioral Medicine, Mind Your Body blog

Moving in the Wrong Direction

Dr Tiffany Taft, Ph.D., Northwestern University, December 13, 2012

IBS Impact IBS Impact blog

Proposed DSM-5 Criteria May Unfairly Label Physical Conditions as Psychological Disorders

The most recent proposals for new category “J 00 Somatic Symptom Disorder”

Ed: Proposals, criteria and rationales, as posted for the third stakeholder review and comment period, in May 2012, were removed from the DSM-5 Development website on November 15, 2012 and placed behind a non public log in. Criteria as they had stood for the third draft can no longer be viewed but are set out on Slide 9 in this presentation, which note, does not include the three, optional Severity Specifiers that were included in the third iteration.

Note that the requirement for “at least two from the B type criteria” was reduced to “at least one from the B type criteria” between the second and third set of draft proposals.

IASP and the Classification of Pain in ICD-11  Prof. Dr. Winfried Rief, University of Marburg,

Slide 9

Related material

Somatic Symptom Disorder could capture millions more under mental health diagnosis

Submission to Somatic Symptom Disorder Work Group in response to third draft proposals

Filed under Allen Frances, American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

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