Somatic Symptom Disorder in DSM-5: You’re Crazy to Worry about Your Health

by Phil on April 9, 2013

In DSM-IV, there is a category called Somatoform Disorders, the common feature of which is a preoccupation with “… physical symptoms that suggest a general medical condition …and are not fully explained by a general medical condition…”

Four of the “diagnoses” in this category will be retired in DSM-5 and will be replaced by a new “diagnosis”:  somatic symptom disorder.  The four superseded “diagnoses” are:

1.  somatization disorder
2.  hypochondriasis
3.  pain disorder
4.  undifferentiated somatoform disorder.

Here’s a brief synopsis of the four old “diagnoses.”

1.  S.D:  A history of at least 8 specific symptoms over a period of several years with no valid medical explanation.
2.  H:  A persistent fear of illness based on misinterpretation of symptoms.
3.  P.D:  Reported severe pain that is judged to be primarily psychological in origin and maintenance.
4.  U.S.D:  Similar to somatization disorder, but with fewer complaints and of shorter duration.

The common thread through all four of these “diagnosis” is that the individual is reporting pains or various other physical symptoms to a degree that is judged excessive, and in the absence, despite investigation, of any underlying physical pathology.

DSM-5

As mentioned earlier, the four retiring “diagnoses” will be replaced in DSM-5 by somatic symptom disorder, the essential feature of which is a disproportionate and persistent concern (lasting at least 6 months) about the medical seriousness of one’s symptoms – even if the symptoms arise from a genuine confirmed illness!

In other words, if you have cancer or diabetes or kidney failure, and your worries and concerns about your illness are – in a psychiatrist’s judgment – excessive, then you can be “diagnosed” with this “mental illness.”

By what stretch of the imagination, you might ask, can they justify such a move?  I can’t do justice to their cognitive gymnastics, so I’ll let them speak for themselves.

SOMATIC SYMPTOM DISORDER
“DSM-5 better recognizes the complexity of the interface between psychiatry and medicine. Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition. The relationship between somatic symptoms and psychopathology exists along a spectrum, and the arbitrarily high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum. The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained symptoms. Individuals previously diagnosed with somatization disorder will usually meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms.”

MEDICALLY UNEXPLAINED SYMPTOMS
“DSM-IV criteria overemphasized the importance of an absence of a medical explanation for the somatic symptoms. Unexplained symptoms are present to various degrees, particularly in conversion disorder, but somatic symptom disorders can also accompany diagnosed medical disorders. The reliability of medically unexplained symptoms is limited, and grounding a diagnosis on the absence of an explanation is problematic and reinforces mind -body dualism. The DSM-5 classification defines disorders on the basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms).”  APA: Highlights of Changes from DSM-IV-TR to DSM-5, p 10-11

“Comprehensive assessment of patients requires the recognition that psychiatric problems often co-occur in patients with medical problems. While DSM-IV was organized centrally around the concept of medically unexplained symptoms, DSM-5 criteria instead emphasize the degree to which a patient’s thoughts, feelings and behaviors about their somatic symptoms are disproportionate or excessive. The new narrative text for SSD notes that some patients with physical conditions such as heart disease or cancer will indeed experience disproportionate and excessive thoughts, feelings, and behaviors related to their illness, and that these individuals may qualify for a diagnosis of SSD. This in turn may enable them to access treatment for these symptoms. In this sense, SSD is like depression; it can occur in the context of a serious medical illness. It requires clinical training, experience and judgment based on guidance such as that contained in the DSM-5 text to recognize when a patient’s thoughts feelings and behaviors are indicative of a mental disorder that can benefit from focused treatment.

This change in emphasis removes the mind-body separation implied in DSM-IV and encourages clinicians to make a comprehensive assessment and use clinical judgment rather than a check list that may arbitrarily disqualify many people who are suffering with both SSD and another medical diagnosis from getting the help they need.” APA: Somatic Symptom Disorder p 2

These quotations are not very comprehensible.  In fact they are more spin than substance, and can only be understood in the context of what the APA has done.

It’s a widely accepted fact that some people do indeed worry to a considerable degree about illnesses that they believe they have, even though repeated examinations by physicians produce no evidence of illness.  Sometimes, of course, the doctors are wrong, but very often they are correct, and the individual is in effect worrying about a non-existent condition.  For decades the APA has labeled these individuals as mentally ill.  (Obviously I conceptualize the matter differently, but let’s put that issue aside for now.)

With DSM-5, the APA has increased the number of people who will be embraced by this “illness,” and they’ve done this in two ways.  Firstly, by the simple expedient of relaxing the criteria for inclusion.  They do this by reducing the minimum number of symptoms of which the individual is complaining (from 8 to “no minimum,” which presumably means 1!) and the duration of the complaints (from “several years” to 6 months!)

This, of course, is bad enough, but in addition they have added an entirely new group of potential victims: people who have a real illness about which they worry to a degree that a psychiatrist considers excessive!  So now, by APA fiat, and the world-wide release of the long-awaited DSM-5, these individuals, in addition to cancer, diabetes, kidney failure, arthritis, or whatever real ailment they have…also have a mental illness, and can be legitimately drugged into oblivion by anyone with a prescription pad.

And remember, there’s no evidence to support this change.  Like everything else in the DSM, it’s just because the APA decided.

In this light, let’s go back and look at their justification for these changes.

“The relationship between somatic symptoms and psychopathology exists along a spectrum, and the arbitrarily high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum.”

For decades we mental illness “deniers” have been drawing attention to the fact that virtually every problem listed in DSM occurs on a continuum, and that the cut-offs and categorizations are arbitrary and do not reflect these continua.  And for decades, the APA ignored this.  But now, suddenly, it’s important.  But – and this is the critical point – instead of recognizing this continuum (or spectrum, as they call it), they are simply substituting an arbitrarily low cut-off (1) for an arbitrarily high cut-off (8).

“DSM-IV criteria overemphasized the importance of an absence of a medical explanation for the somatic symptoms. Unexplained symptoms are present to various degrees, particularly in conversion disorder, but somatic symptom disorders can also accompany diagnosed medical disorders. The reliability of medically unexplained symptoms is limited, and grounding a diagnosis on the absence of an explanation is problematic and reinforces mind -body dualism.”

Why, you might ask, is the old DSM-IV requirement (that the symptoms be unexplained), which has been the defining feature of these “diagnoses” for at least four decades, now considered an over-emphasis?  Because “… the reliability of medically unexplained symptoms is limited.”  In other words, sometimes the medics get it wrong, and the person really does have an illness.  What’s tragically funny about this is that I can’t imagine any bona fide medical specialty whose diagnostic/nosological system has poorer reliability than the DSM.  But because we can’t be sure that the doctor is correct when he says the person isn’t sick, we must abandon this whole aspect of the “diagnosis.”

The other stated problem with the old system is that it “reinforces mind-body dualism.”

In other words, the old DSM-IV concept (that the person is worrying about a disease that he doesn’t really have) reinforces mind-body dualism.  And lumping these individuals in with people who worry about a disease that they do really have, somehow counters this pernicious trend?  The fact is that worrying about a disease, real or fictitious, has no bearing whatsoever on mind-body dualism.  It’s just more APA nonsense.

But it gets even worse.  They are retaining conversion disorder and pseudocyesis (false pregnancy) in DSM-5 (with their requirements of medically unexplained symptoms!)  “…because it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical pathophysiology.”  And this, you see, does not reinforce mind-body dualism.

When you consider the damage that psychiatrists have done and continue to do to millions of people, with their spurious diagnosing, their routine subordination of science to spin, their disempowering of the individuals they “serve,” and their pill-for-every-problem philosophy, their present pursuit of intellectual purity with regards to mind-body dualism is a little difficult to fathom.

The APA’s justification for the changes is what con-artists call a smoke-screen.  The APA’s agenda for the past 50 years has been the expansion of the diagnostic maw and the pushing of drugs onto more and more people.  They do this to expand their turf and their incomes, and to maintain an ever-increasing flow of profits for their pharmaceutical allies.  DSM-5 is just more of the same – only worse.  Don’t be fooled by the spin.  And remember, 69% of the DSM-5 task force have ties to the pharmaceutical industry.  But we don’t have to worry about this, because the APA has assured us that these ties did not affect their professional judgment in any way.

The question I find myself asking almost constantly with regards to the APA is:  where do they find the gall.  How can they go on promoting this intellectual travesty and this reckless destruction of human life?  How can they be so crassly self-serving and so indifferent to the plight of their victims?

And just as I’m beginning to think that they surely can’t get any worse, they produce somatic symptom disorder.  By what perverted chain of reasoning do they consider themselves qualified to decide the appropriateness or otherwise of a person’s reaction to contracting a serious illness?  Have they finally lost all sense of proportion and decency?

Please – if you’re not already doing so – speak out against DSM-5.

 

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  • me.agenda

    I comment as a UK advocate who has been monitoring and reporting on the SSD Work Group’s deliberations since early 2009.

    Your readers may be interested in the recent BMJ commentary by Allen Frances, MD, (Published 19 March 2013) with nearly 30 “Rapid Responses” from professionals, advocates and patients:

    http://www.bmj.com/content/346/bmj.f1580

    The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill BMJ 2013;346:f1580

    BMJ Press release: http://www.bmj.com/press-releases/2013/03/18/new-disorder-could-classify-millions-people-mentally-ill

    The commentary prompted this rebuttal from SSD Work Group Chair, Joel E Dimsdale, and the two British members of the SSD Work Group, Profs Michael Sharpe and Frances Creed:

    http://www.bmj.com/content/346/bmj.f1580/rr/637052

    In a counterpoint response to Allen Frances’ May 2012 New York Times Op Ed piece, APA stated:

    “…There are actually relatively few substantial changes to draft disorder criteria. Those that have been recommended are based on the scientific and clinical evidence amassed over the past 20 years and then are subject to multiple review processes within the APA.”

    The Somatic Symptom and Related Disorders chapter is one section for which substantial changes to existing definitions and criteria are being introduced but with no body of rigorous evidence to support the SSD construct – a construct already influencing proposals for a new ICD classification, “Bodily Distress Disorder”, being field tested for the WHO’s ICD-11 and the ICD-11-PHC (primary care) version, and proposed to replace several of ICD-10′s existing Somatoform Disorder categories.

    APA is proposing to operationalize an entirely new disorder of its own devising, using highly subjective criteria for which no significant body of research into reliability, validity, safety has been published, that will capture adults, children, adolescents and elderly people with diverse illnesses.

    It is also of concern that the SSD work group has yet to publish any projections for prevalence estimates and the potential increase in mental health diagnoses across the entire disease landscape, nor on the projected clinical and economic burden of providing CBT and similar therapies for patients for whom an additional diagnosis of Somatic Symptom Disorder has assigned.

    15% of the ‘diagnosed illness’ study group (cancer and coronary disease) met the criteria for an additional diagnosis of SSD in the DSM-5 field trials; in the ‘functional somatic’ study group (irritable bowel syndrome and chronic widespread pain), 26% were coded with SSD.

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

    In February, Dr Dimsdale told journalist, Susan Donaldson James, for ABC News:

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

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

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

    And there has been plenty of time: the SSD Work Group set out its framework in mid 2009:

    “[The SSD Work Group's] framework will allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome”

    Extract: Dimsdale J, Creed F. DSM-V Workgroup on Somatic Symptom Disorders: the proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report. J Psychosom Res 2009;66:473-6.

    and

    “These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis. Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met.”

    Extract: DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions PDF document, published February 2010, updated May 2011 for the first and second draft stakeholder reviews.

    Suzy Chapman
    http://dxrevisionwatch.com

  • me.agenda

    For further reading, I also suggest:

    Somatic Symptom Disorder could capture millions more under mental health diagnosis, Suzy Chapman, May 26, 2012: http://wp.me/pKrrB-29B

    and

    Mislabeling Medical Illness As Mental Disorder Allen Frances, MD, Psychology Today, DSM 5 in Distress, December 8, 2012

    Why Did DSM 5 Botch Somatic Symptom Disorder? Allen Frances, MD, Psychology Today, Saving Normal, February 6, 2013

    Suzy Chapman
    http://dxrevisionwatch.com

  • Phil_Hickey

    Suzy,

    Thanks for coming in. Your comments are pertinent and appreciated.

  • Falco

    “Of course, the presence of suspicion of itself does not justify this [i.e., paranoid personality] diagnosis, since the suspicion may be warranted in some instances.” (dsm ii, p. 42)

    That warning has been omitted since long.

  • Phil_Hickey

    Falco,

    Thanks for coming in. It’s an interesting point. In DSM-5 the wording is: “…suspects, without sufficient basis,…”

    But who decides what’s sufficient.?

  • Falco

    Canadian medical historian Edward Shorter says what makes it into the DSM is more the result of “a lot of horse-trading around the table” than science.

    “‘I’ll give you your diagnosis if you give me mine,’ which is a fundamentally unscientific process,” says Shorter. “They didn’t come up with the speed of light this way.

    “Psychiatry claims to be a medical specialty that is based on neuroscience, but the whole diagnostic system is very questionable,” said Shorter. “The current DSM series is, in my view, a scientific disaster and should be discarded.”

    http://www.canada.com/vancouversun/news/westcoastnews/story.html?id=15d1a26a-1d6a-491b-92c7-35db47541e9c&k=57777&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+canwest%2FF262+(Vancouver+Sun+-+WestCoast+News)

  • Phil_Hickey

    Falco,

    Thanks for coming back. I agree wholeheartedly.

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