Many faces of somatic symptom disorders, International Review of Psychiatry

Many faces of somatic symptom disorders, International Review of Psychiatry February 2013

Post #234 Shortlink:


Buried within the ‘Disorders Description’ document, published with the Somatic Symptom Disorders Work Group proposals for the second DSM-5 stakeholder review, are three brief references to children:

“The presentation of these symptoms may vary across the lifespan. A corroborative historian with a life course perspective may provide important information for both the elderly and for children.”

“PFAMC [Psychological Factors Affecting Medical Condition] can occur across the lifespan. Particularly with young children, corroborative history from parents or school can assist the diagnostic evaluation.”

“In the elderly somatic symptoms and comorbid medical illnesses are more common, and thus a focus on criteria B becomes more important. In the young child, the ‘B criteria’ may be principally expressed by the parent.” [1]

1 Somatic Symptom Disorders Work Group ‘Disorders Description’ document, Second draft review, May 2011

APA evidently intends its new Somatic Symptom Disorder for application in children with chronic, distressing symptoms; or where the parent of a child with chronic, distressing symptoms is perceived to be expressing ‘disproportionate and persistent concerns,’ or ‘maladaptive’ coping strategies, or devoting ‘excessive time and energy’ to [a child’s] symptoms or health concerns or demonstrating ‘dysfunctional and maladaptive beliefs’ about symptoms or disease.

The finalized texts that expand on disorder descriptions in the DSM-5 manual are under embargo and it won’t be known until May what guidance (if any) is included for practitioners for the application of SSD and PFAMC in children and adolescents.

But there are no specific references, guidance or cautions for the application of SSD or PFAMC in children within the draft criteria sets, as they had stood at the last stakeholder review, nor within the proposals and brief rationale texts published with the third draft.

And there are no specific references to the application of PFAMC in children, or SSD in children and parents within the APA’s Somatic Symptom Disorder Fact Sheet or the Highlights of Changes from DSM-IV-TR to DSM-5 document, or in this Mark Moran Psychiatric News article justifying the proposals.

Not surprising, then, that the use of this new SSD construct in children and young people, or as applied to the parent(s) of a child with chronic somatic symptoms has received little discussion within the field or in the advocacy arena.

In DSM-IV-TR, PFAMC was listed under ‘Other Conditions That May Be a Focus of Clinical Attention.’ For DSM-5, APA has approved the shifting of PFAMC “from its obscure place in the back of prior DSM editions into the Somatic Symptom Disorders chapter” where it now attracts a mental disorder code. (Another issue that has attracted scant attention.)

What evidence for safety of application of SSD in children?

Very little is known about the APA’s field trials for what was at that point known as ‘CSSD’ (Complex Somatic Symptom Disorder). There is no publicly available information on patient selection or study design.

The make-up of the three field trial study groups was presented at conference as: a ‘diagnosed illness’ group (n=205), comprising patients with cancer or coronary disease; a ‘functional somatic’ group (n=94), comprising patients with irritable bowel syndrome and ‘chronic widespread pain’ (a term often used as an alternative to ‘fibromyalgia’; and a considerably larger ‘healthy’ control group.

There is no evidence that either SSD or PFAMC has been field tested by APA or investigated by any other group for safety and reliability of application in children and young people – an issue raised in my recent BMJ Rapid Response: What evidence for safety of application of SSD in children? March 27, 2013.

The lack of a body of rigorous evidence to support the validity and safety of the new SSD construct in adults (and especially in older patients who are more likely to be living with multiple age onset diseases and subject to polypharmacy and the potential for somatic symptoms resulting from medication side effects or drug interactions) is disturbing.

Joel Dimsdale’s insouciant, “If it doesn’t work, we’ll fix it in the DSM-5.1 or DSM-6” is particularly disturbing in the absence of evidence for the safety and validity of the application of SSD in children and adolescents.

For ICD-11, the current proposal is to replace or subsume six or seven existing ICD-10 Somatoform Disorder categories with a new category, Bodily Distress Disorder. According to emerging proposals for ICD-11-PHC (the primary care version of ICD-11), BDD is proposed to include DSM-5‘s new [C]SSD [1] [2].

Does ICD-11 intend its proposed BDD to be applied to children and adolescents? On what evidence does the ICD-11 working group for the revision of ICD-10’s Somatoform Disorders, the Topic Advisory Group for Mental Health, the ICD-11 Revision Steering Group and WHO classification experts rely for the validity of BDD as a construct and its application in children?

1 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 Sample Chapter 2: Page 50
2 Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry 2012;24:556-67. PMID:23244611

Other than the two papers, below, I have yet to find any other papers which reference or specifically discuss the operationalization of the SSD criteria in children and adolescents.

Schulte IE, Petermann F: Somatoform disorders: 30 years of debate about criteria! What about children and adolescents? J Psychosom Res 2011; 70:218-228. [PMID: 21334492] Abstract

“The aim of this study was to evaluate the suitability of the complex somatic symptom disorder, proposed by the DSM-V Somatic Symptom Disorders Workgroup, in classifying children and adolescents who suffer severely from medically unexplained symptoms.”

That paper is cited by this 2012 paper, below, for which a full PDF is available:

Ghanizadeh, G, Ali Firoozabadi, A. A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V. Psychiatria Danubina 12/2012; 24(4):353-8.

which addresses a question, “Is it suitable for children and adolescents?” under “SOME OTHER CHANGES AND CONCERNS ABOUT NEW CLASSIFICATION”

If readers are aware of other papers discussing the application of SSD in children I’d be pleased to have information.

Many faces of somatic symptom disorders, International Review of Psychiatry February 2013

As far as one can tell from the abstracts, none of the recently published papers below appears to discuss the application of the new SSD diagnosis in children, young people and families:

A free access editorial and abstracts for 11 papers in the February issue of International Review of Psychiatry:

Volume 25, Number 1 (February 2013) Somatic Symptoms Disorders

Please refer to site for links to free Abstracts and subscription papers.

GUEST EDITOR: Santosh K. Chaturvedi

Many faces of somatic symptom disorders
Santosh K. Chaturvedi

International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 1–4.

Free PDF Plus:

Somatic symptom disorders and illness behaviour: Current perspectives
Kirsty N. Prior, Malcolm J. Bond
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 5–18.
Diagnostic criteria for psychosomatic research and somatic symptom disorders
Laura Sirri, Giovanni A. Fava
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 19–30.
Measurement and assessment of somatic symptoms
Santosh K. Chaturvedi, Geetha Desai
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 31–40.
Somatization and somatic symptom presentation in cancer: A neglected area
Luigi Grassi, Rosangela Caruso, Maria Giulia Nanni
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 41–51.
Somatic symptoms in consultation-liaison psychiatry
Sandeep Grover, Natasha Kate
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 52–64.
Association of somatoform disorders with anxiety and depression in women in low and middle income countries: A systematic review
Rahul Shidhaye, Emily Mendenhall, Kethakie Sumathipala, Athula Sumathipala, Vikram Patel
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 65–76.
‘I’m more sick than my doctors think’: Ethical issues in managing somatization in developing countries
Prabha S. Chandra, Veena A. Satyanarayana
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 77–85.
Review of somatic symptoms in post-traumatic stress disorder
Madhulika A. Gupta
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 86–99.
Somatic symptoms in primary care and psychological comorbidities in Qatar: Neglected burden of disease
Abdulbari Bener, Elnour E. Dafeeah, Santosh K. Chaturvedi, Dinesh Bhugra
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 100–106.
Psychopharmacotherapy of somatic symptoms disorders
Bettahalasoor Somashekar, Ashok Jainer, Balaji Wuntakal
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 107–115.
Behavioural and psychological management of somatic symptom disorders: An overview
Mahendra P. Sharma, M. Manjula
International Review of Psychiatry Feb 2013, Vol. 25, No. 1: 116–124.

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

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

Post #217 Shortlink:

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

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