The following is for anyone that has come in late to this subject.
It is an overview to help you put in a short submission to the American Psychiatric Association.
Feel free to use what is here,
but please do not cut and paste. To be effective, submissions must be original
Why this is important for persons in or outside of the USA
This will affect persons in the USA directly, but will also affect persons in other countries because DSMs are already used to varying degrees in countries outside of the USA.
It will apply to ME CFS FMS & XMRV
It will apply
to all medical conditions, including persons with a ME CFS XMRV or FMS diagnosis.
The outcomes of some of the suggested reforms for persons with ME CFS FMS XMRV has some troubling considerations.
Please take some time to write and make a short submission expressing your concerns to the APA.
The deadline for submissions is
15th June 2011
DSM 5 - OVERVIEW: WHAT IS IT & WHATS IT ALL ABOUT
1. What is the DSM 5 and who is responsible for its modifications?
The APA is responsible for publishing the diagnostic manual on psychiatric illnesses. This is called the Diagnostic and Statistics Manual (DSM). It defines and classifies psychiatric illness
Currently APA is moving from DSM IV to DSM 5. Roman numerals are no longer employed.
The group within the APA responsible for drafting DSM 5 is called The Somatic Symptom Disorders Working Group (the working group)
2. Terminology
What is a Somatic Illness?
Somatic comes from the Greek word meaning body
In medicine it means of or associated with the body. Therefore somatic symptoms simply means symptoms of the body.
When the psychiatric arm of medicine use this term this is precisely what they mean: an illness of the body. Using this acknowledged medical term, the field of psychiatry believes that there are some somatic illness or symptoms of the body that are caused by a psychological dysfunction. The term somatic is a general medical term and as such, is not taken to mean that illness is caused this way only that the symptoms are of the body.
What is somatisation ?
Somatisation refers to the reporting of a large number of body symptoms to a doctor.
Where they fall into a recognised pattern, this might point to a functional somatic syndrome. CFS, FMS, IBS are examples of such
Health Anxiety (previously referred to as Hypochondriasis) is a related condition and is understood as excessive concerns about health and illness with a preoccupation of fear that they may have a serious disease. This persists despite medical evaluation and re assurance.
3. What changes are being proposed by the APA?
The changes include a proposal to change the existing classification from Somatisation disorders to Somatic Symptom Disorders
Somatisation disorder under prior DSMs : described people who have a history of many medically unexplained bodily symptoms (MUS) that started before the age of 30 years and which have led to repeated visits to doctors and/or significant impairment of occupation or social functioning.(1)
4. What are the reasons for these changes?
Doctors found the old terms confusing and were not fully utilising existing diagnoses
Different definitions meant true prevalence of the illness is not known, but is believed to be higher in clinical practice than initially thought
Some diagnoses required many symptoms and that they be present for many years and some are only concerned with current symptoms. However symptoms wax and wane
Persons in need are going without treatment
Old diagnoses place too much emphasis on medically unexplained symptoms (MUS)
The term MUS is undesirable because:
o It creates mind body dualism and many organic diseases are also can have cognitive disorder
o Patients mistake this term to mean medically undiagnosed and it creates tension
Between doctor and patient
o MUS cannot be reliably assessed
o They create an un necessary financial burden to the health care system
To address these concerns a new classification and will merge a number of diagnostic categories together. This is further justified because the illnesses share:
o Medically unexplained symptoms
o somatic symptoms and cognitive distortions
o involve presentation of medical symptoms and concerns about medical illnesses
The workgroup has combined the following old diagnoses:
Somatoform Disorders,
Psychological Factors Affecting Medical Condition (PFAMC), and
Factitious Disorders
into one group entitled
Somatic Symptom Disorders
This change will also involve a merging of the following existing diagnostic classifications
Somatization disorder
Hypochondriasis
Undifferentiated somatoform disorders
Pain disorder
Factitious disorder will now be moved to the new classification of Other Disorders
So the chapter in draft form, for Somatic Symptom Disorders presently looks like this:
J 00 Complex Somatic Symptom Disorder
J 01 Simple Somatic Symptom Disorder
J 02 Illness Anxiety Disorder
J 03 Functional Neurological Disorder (Conversion Disorder)
J 04 Psychological Factors Affecting Medical Condition
J 05 Other Specified Somatic Symptom Disorder (The work group has not yet proposed criteria for this disorder.)
J 06 Unspecified Somatic Symptom Disorder | Pseudocyesis
4. Complex Somatic Smyptoms Disorder (CSSD) is the diagnosis category most relevant and which makes persons with ME and CFS most vulnerable to a psychiatric diagnosis.
It is not a reclassification or replacement of the existing medical criteria for CFS (Fukuda or other criteria). It will operate in addition to it. It will also apply equally to persons with all other organic diseases. Ie: cancer, heart disease, diabetes. Etc.
5. How do you qualify for a psychiatric diagnosis under CSSD?
There are two arms to this diagnosis.
The first has two main elements that must be present
(i) One or more symptoms that must be distressing or interfere with daily activity
(ii) Symptoms must be Somatic
Somatic symptoms alone (i.e. symptoms attributable to irritable bowel symptom) without cognitive distortion, will not be enough to attract this diagnosis.
If this arm is satisfied then the following three criteria must be satisfied
1. Somatic symptom or symptoms
2. Excessive thoughts, feelings, behaviours related to symptoms or associated health concerns
3. Chronicity: present for more than 6 months
1. Somatic Symptoms
(a) There must be one or more somatic symptoms AND
(b) they are distressing and or result in significant disruption to daily life
2. Excessive thoughts, feelings and behaviours related to symptoms.
Two of the following must be present
(a) High level of health related anxiety
(b) Disproportionate and persistent concerns about medical seriousness of symptoms
(c) Excessive time and energy devoted to these symptoms and or health concerns
3. Chronicity
Any symptom(s) need not be continually present, but the state of being symptomatic exists for 6 months or more.
Where there is a predominance of one aspect of meeting this criteria, optional diagnosis may apply.
For example if there are minimal symptoms but high related anxiety (previously hypochondriasis) the diagnosis of illness anxiety order may be more appropriate
Those whos predominant symptom is pain, might be more appropriately be diagnosed with adjustment disorder or psychological factors affecting a medical condition.
So CSSD may also serve as a portal for other such psychiatric diagnoses as well
6. What illnesses will be caught by CSSD and other SSD classifications?
CSSD criteria will operate as an addition to all existing medical illnesses, whether it is a well recognised organic disease cancer, heart disease, diabetes or a syndrome, such as ME CFS FMS. It will operate in relation to one symptom or many and where there is the defined cognitive distortion.
7. How is it likely to affect persons with CFS & FMS?
It is believed that all persons who:
(i) may be eligible for or
(ii) who in fact have a diagnosis of ME CFS FMS or another syndrome,
would be vulnerable to this psychiatric diagnosis and assessment.
Where a patient has an existing diagnosis of ME CFS FMS, they may receive this psychiatric diagnosis in addition to their existing diagnosis(es). It will therefore bolt onto, your existing medical conditions.
It may also be used as consideration for other psychiatric conditions, where the number of symptoms that create anxiety are lower than those commonly associated with CSSD (i.e. anxiety disorder illness) etc.
SSDs are likely to be treated with CBT and antidepressants.
Further medical testing for persons with MUS and a SSD diagnosis may well be seen as unnecessary and be denied.
Although it remains unclear, these psychiatric diagnosis might also possibly affect:
*insurance payments
*disability support entitlements
*further medical care and treatment
*the right to travel (a mental illness may preclude entry to some countries)
8. Why persons with ME CFS FMS may be vulnerable
1. These illnesses present with a multitude of symptoms that cause distress and interference in daily activity
2. Symptoms fluctuate in number, duration and severity and many persist for more than 6 months.
3. Symptom number, type and variability make these illnesses stand out from others and carry an understandable level of anxiety. The new proposed CSSD diagnoses provides no objective marker as to what constitutes high and or excessive levels of anxiety or concern or behaviour to assess the complex illnesses or for persons with multiple health issues.
4. Levels of severe disability means many patients cannot make regular attendances to a doctor and repeating their symptoms or concerns over a period greater than 6 months may put them at risk for a CSSD diagnosis.
5. Current attitudes and a lack of adequate medical care can make attendances to doctors or ER an anxious affair, which might be mistaken for general anxiety about symptoms.
6. A lack of understanding on the nature and complexity of the illnesses by many doctors currently causes:
*patients being views as hypochondriacs
*patients health issues as being too difficult and time consuming
and this presents a danger that such doctors will assign these diagnoses and may in some instances choose to treat this as the primary diagnosis. This may preclude a patient seeking further medical assistance for the management of symptoms or investigation of other organic diseases.
9. Will the new SSD diagnoses lead to an increase in psychiatric diagnoses?
The APA remains uncertain but states:
Not necessarily. It may act as a portal with classifications to other psychiatric illness i.e.; anxiety illness disorder, adjustment disorder etc.
There is a lot of data however, which supports the idea that physicians find the old diagnoses confusing. This suggests there will be an increase in the use of and the diagnoses made under CSSD. (2)
Studies suggest that more than 75% of hypochondriasis patients would meet the diagnosis for CSSD. Those with high illness anxiety and minimal symptoms that fit CSSD would meet and more appropriately be diagnosed with illness anxiety disorder under DSM V proposals. (3)
As many doctors currently view ME CFS and FMS as hypochondriacs the above statistic indicates the danger that exists for patients to be assigned to this diagnostic criteria.
It might have been a good idea for the APA to know the impact of this in relation to syndromes that can sometimes be initially dismissed as simply random medically unexplained symptoms. With over 115 syndromes alone, as it may place a large demand on existing psychiatric services that cannot be met. There is evidence to suggest that this is a reasonable possibility based on events overseas. (4)
REFERENCES
1. Creed, Henningsen, Fink: Patients with medically unexplained symptoms and somatisation a challenge for European health care systems a draft White Paper for the European Association for Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) MUS working group. See:
http://dxrevisionwatch.wordpress.com/2010/...controversies/
2. APA Rationale for DSM 5 modifications
http://dxrevisionwatch.wordpress.com/2011/...ematic-part-2/
3. Ibid
4. See fn 1
Further good reference material can be found here:
http://wp.me/PKrrB-AQ
