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Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders?

Discussion in 'Other Health News and Research' started by Dolphin, Feb 19, 2017.

  1. Dolphin

    Dolphin Senior Member

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    I thought this short article makes some good points about the problems of the Medically Unexplained Symptoms diagnosis.

     
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  2. alex3619

    alex3619 Senior Member

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    Pretty well. Here I am responding to the excerpt, I need to read the full article.

    It left out logical fallacies in the thinking, though did point out the main foci of such fallacies. It also does not discuss the pseudoscientific methodologies used in this research.

    The thing I find annoying about unjustified mind-body dualism is that, not only are the mind and body treated as separate, they want to describe them as the same. Mind is just another part of body, but its a special (satirical accent on special) kind.

    The time to focus on "mind" is over. Its an obsolete term, like ether, phlogiston, etc. Using it keeps us in the age of ignorance.
     
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  3. trishrhymes

    trishrhymes Senior Member

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    Looks promising. It's behind a paywall - I'd like to see the rest...
     
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  4. AndyPR

    AndyPR Senior Member

  5. DeceptivelySlow

    DeceptivelySlow

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    Looks to me the quoted material raises some good points. Research and symptoms I have come across suggest the body-mind neural connection plays a significant role in emotions which I find fascinating. That is there is a very direct connection from the body generating what is in the mind (or at least that feed back loop is necessary to generate what is in the mind). To me this further validates that the conversion disorder concept is complete bullocks.

    For example doctors are successfully treating PTSD with a sympathetic neural block. A psychological issue being treated with something as "electrical/mechanical" as a neural block. I think there are some significant implications there.
     
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  6. trishrhymes

    trishrhymes Senior Member

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    Hmm, not sure about this. It makes some good points about not assuming that because a patient has had an MUS label put on them, it doesn't mean all future symptoms should be ignored, and that MUS simply means the cause hasn't yet been found.

    However, he seems to conclude that there is a role for psychiatry in dealing with physical symptoms because there is influence by the mind on how we perceive the severity of our symptoms, whether explained or unexplained.

    Personally, I find physical symptoms such as pain hardest to live with when I am frightened that there is something sinister going on that I don't understand. The thing that makes this pain more manageable is good scientific investigation and understanding of what is wrong, and, if necessary, pain relieving medication, not some psych messing in my head, thank you.
     
  7. xrayspex

    xrayspex Senior Member

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    yes this is fascinating to me....firstly because I have chronic pain and fatigue. but I am curious about chicken/ egg with physical and cognitive ----it seems like it can't be just one way or the other. there are clearly a lot of people without chronic physical pain and fatigue who have been mightily helped by the work of people like David Burns a cognitive therapist who has written many books instructing people how to change their outlook and feelings by deconstructing and restructuring their thoughts and it can be very effective. To a degree it can also help some other physically chronically ill folks deal with tough situations....I find it difficult territory to navigate in my own understanding of what it is all about as well as trying to have conversations with those that don't understand the nuances, maybe because they have been pleased with their results of navigating "mind over matter" and I can tell they sometimes can't help but think maybe you just need to try harder.

    so how do you figure that out, determine which people can start at the point of thought-- catching their thought, changing it and having a more positive outcome vs those that won't work for? Some things it seems clear that you are going to have pain right away before any thoughts such as putting hand on a hot stove accidentally or something (or is that clear? can Tony Robbins and some gurus living in the mountains prevent that pain with their minds? I dunno)....but when you get into something like spinal pain it seems so tricky, or inflammatory pain.....I am trying to do what I can thru nutrition, rest, pacing and my mind etc to deal because there are no better tools I can tolerate available to me at this point in history that I am aware of so I am interested in understanding how far I can work with my thoughts emotions and behaviors but trust me I get really frustrated if a friend or medical person tries to play judge or director of that.......I know when something is beyond my control and have done the best i can.......

    its a quandary that can cause me great frustration and anger if I don't do a bunch of CBT on myself lol
     
  8. xrayspex

    xrayspex Senior Member

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    yes this sort of thing like the neural block is really of interest to me and relates to my quandary of how to figure out when something needs a physical approach like a block or meds or if you can make good headway with working mostly on thoughts and emotions. I feel very empathetic to people who have "only" a known psychological diagnosis, who don't actually present with a physical complaint but they can't get better with psych therapy--I bet people sometimes are the hardest on them thinking they aren't trying hard enough--the neural block for ptsd a psych diagnosis is great example of how the realm of what is considered "mind"/psych is not fully understood and sometimes responds best to physical intervention and not something like CBT. and like Alex was saying, talking about mind/body in that old way is sort of passe....but I want to find better language and concepts that I can easily use to help myself and others..........what is a working paradigm that can allow for the group of people with severe chronic pain or other "real" illnesses making progress with mindfulness and thought-work but others that need a neural block or other meds to make any progress?
     
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  9. Snowdrop

    Snowdrop Rebel without a biscuit

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    Some good points.

    Is there a link to this that I can tweet?

    Re: mind-body unity/dualism

    Is there not a case to be made for separating (for the purpose of understanding functioning) the brain from mind?
    The way I see it brain is just another organ of the body. Biochemistry happens in the brain as elsewhere. It can get sick whether with cancer or chemicals out of balance can cause depression or the electrical system can malfunction causing seizures.

    The mind is more than the sum of it's parts so to speak. It is not brain. It is the interplay between our body (including brain) and the world we experience. Because we have self-awareness there is more to our functioning than the biochemical actions taking place in the brain. All animals respond to their environment we respond 'thoughtfully' or 'reflectively' giving rise to a more nuanced way of responding to our environment.

    As a result of this kind of thinking we can also feel moods that are functionally problematic. So we feel depressed. Perhaps brain chemistry responds? This means that not everyone with depression (as an eg) will not have major life issues that need resolving since some have as primary brain malfunction in the context of a more or less normally satisfying life.

    We can't have mind without the body but we can't have mind without something outside ourselves either.

    To me this is the problem with the new mind-body speak. I's vague and it really signifies nothing. It's not science. And it allows for non-science interpretations of physical symptoms/illness. People tend to like this mind-body unification without really parsing what is meant by it--it just appeals to the concept of unity and wholeness. It is superficial. And harmful. It needs to be examined more closely as to it's meaning or any MUS can be mental phenomena because the mind and the body are one.
     
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  10. DeceptivelySlow

    DeceptivelySlow

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    I tend to get angry along with many others when some sort of psychological causality and ME/CFS get mentioned together. The articles points out some problems with that line of thinking which is good. I firmly convinced any psychological issue associated with ME/CFS is a side affect and has zero causality other than possibly aggravating symptoms. Anxiety is something that jumps out at me as possibly side affect from a malfunctioning ANS but mental stress can certainly aggravate this issue.
     
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  11. xrayspex

    xrayspex Senior Member

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    snowdrop, good points about distinction and intersections of mind/brain

    your last paragraph tho is part of the quandary, I want to find legitimate way thru it to make sense and make most of it.....Norman Doidge who has written a couple of books (I have both) about brain research around the world that is promising for chronic health problems I think navigates the territory pretty respectfully and intelligently
     
  12. alex3619

    alex3619 Senior Member

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    When I read "mind" I interpret that as "brain function". The idea of mind as an entity, a thing, something separate, is from an age in which we believed that life could spontaneously arise, that miasma caused disease, and that women had wandering wombs.

    To me the brain is the physical thing, what the brain is, and what we call mind, and a lot of other aspects of brain, are what the brain does. Labeling this "entity" "mind", as separate from brain and brain function, remains an unproven hypothetical construct, and leads to errors in reasoning. Its useful in everyday discussion, but does not have any scientific validity at all. Its just accepted as such far too often.

    Think of it this way. Any machine is just a stack of parts put together in a particular way. What it does is a separate idea from what it is. How we use it is often a different type of idea as well. If you know enough about how a machine works you can describe the function of the parts toward any specific action it makes, such as with a car engine. If you consider a situation in which you know nothing about car engines, never open the hood, and make guesses about what is going on, then you have about summed up our understanding of mind. I am deliberately not using a computer analogy as I think that is also flawed, maybe even more flawed.

    There are learning loops for the brain that include internal and external stimuli, including what we call information, language, experience, etc. This can deeply complicate any consideration of brain function. However what and how the brain learns is implicit in its physical structure and molecular function. It cannot learn things it has no capacity to learn. A lot of psychogenic claims are outrageous claims about what the "mind" (brain) can do.
     
    Last edited: Feb 19, 2017
  13. A.B.

    A.B. Senior Member

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    Why psychosomatic diagnoses are disliked: it's fairly obvious they are pseudoscience, and of no value to the patient (but of some value to those promoting the concept).

    I have never seen a clear and detailed explanation for how these illness are even supposed to work! The entire idea is based on magical thinking.
     
    Last edited: Feb 19, 2017
  14. alex3619

    alex3619 Senior Member

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    Cite that some time where they have an opportunity to reply and watch the psychobabble fly. I have said that in response to media article comments. :whistle:
     
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  15. anciendaze

    anciendaze Senior Member

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    It might be amusing to ask proponents of this approach how they do differential diagnosis to diagnose the following known medical conditions: pituitary hypophysitis, damage to vagus nerve, damage to dorsal root ganglia, diffuse (e.g. diabetic) neuropathy. I'm just assuming it would be a waste of time to ask if they have read this well-known reference on autonomic failure. Questions about the enteric nervous system would also be likely to draw blanks. All these things are "somebody else's problem". You might then wonder what medical problems are actually within their specialization. The answer may be none. Like inquisitors of old, they are more interested in identifying a patient's moral failings.

    All the named conditions are more likely to be apparent to patients before they produce clinical signs. Rare exceptions like herpes zoster show that persistent infectious disease in, e.g. dorsal root ganglia, does take place. This is detected by convenient clinical signs which other infections or causes need not produce.

    Added: In the above I left out a problem with a definite organic cause that can be verified through objective tests, but may produce a bewildering range of somatic symptoms: cervical spinal stenosis. (This cervix is the neck, not the uterine cervix.) Naively, one might guess that this had a 50/50 chance of producing signs in motor nerves a physician might confirm, since about half the nerves through these vertebra are afferent nerves. Since you might also assume that some impairment of afferent nerves would result in definite paresthesias, which could be mapped to isolate the location of the damage, you might even guess that most such problems are caught by doctors. Clinical reports are much less reassuring. I can't really estimate what percentage of problems due to this are currently being caught by ordinary medical doctors and referred to appropriate specialists. There is no lack of reports of problems caught only after years of ineffective treatment based on assumptions of MUS.
     
    Last edited: Feb 20, 2017
  16. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

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    You appear to have missed that when he published that paper, Joel E Dimsdale was Chair of the DSM-5 Work Group for Somatic symptom disorders.

    He and his colleagues, which had included Francis Creed and Michael Sharpe, signed off on the SSD criteria.

    See

    Why Did DSM 5 Botch Somatic Symptom Disorder?
    Allen Frances (with Suzy Chapman), Psychology Today, Saving Normal
    February 6, 2013

    and

    Bad News: DSM 5 Refuses to Correct Somatic Symptom Disorder Allen Frances (with Suzy Chapman), Psychology Today, DSM 5 in Distress
    January 16, 2013


    Allen Frances had had already appealed to the APA Board of Trustees suggesting a redraft of the criteria. He then met up with Dimsdale in San Diego before the draft was finalized to try and persuade him to redraft the criteria and tighten them up.

    Dimsdale took no notice of Allen (who had drafted the DSM-IV Somatoform disorders criteria) and the SSD criteria went ahead with criteria that were even more inclusive than those that had been presented for the second public review and comment exercise.

    It wasn't just the APA Board and DSM-5 Task Force who had rejected Allen Frances' suggestions for a redraft - they had also been rejected by Dimsdale, himself.
     
    Last edited: Jan 1, 2018
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  17. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

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    On March 19, 2013, Allen Frances had a commentary on SSD (which I co-authored) published under his name only in the BMJ:

    The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill

    BMJ2013; 346doi: https://doi.org/10.1136/bmj.f1580 (Published 19 March 2013) Cite this as: BMJ 2013;346:f1580

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


    The commentary was press released a few days before publication. Dimsdale, Sharpe and Creed had been the first to respond with a Rapid Response:


    20 March 2013
    Joel E. Dimsdale
    Professor of Psychiatry Emeritus
    University of California San Diego
    9500 Gilman Dr, San Diego, CA 92093

    Michael Sharpe, M.D., Oxford,
    Francis Creed, M.D., Manchester




    Re: The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill

    Twenty years ago, Dr. Frances chaired the DSM taskforce, which emphasized “medically unexplained symptoms” as the key feature of somatoform disorders. Where has that got us?

    Patients feel that their complaints are viewed as inauthentic, and doctors can’t agree about what is or is not medically unexplained. All of this reinforces a mind-body dualism, which is more consonant with the 17th century than the 21st . Psychiatric symptoms and general medical symptoms can and do coexist. We think and feel with our brains and are affected by life experience and the cellular milieu that we live in.

    The DSM 5 diagnosis of somatic symptom disorder represents an attempt to correct these problems in DSM IV. The DSM 5 diagnosis does not question the reality of patients’ suffering and emphasizes instead that psychiatric disorders are more properly diagnosed on the basis of features such as disproportionate and excessive thoughts, feelings, and behaviors, rather than by negative features like “medically unexplained symptoms.”

    Frances complains that the DSM 5criteria will be “too loose.” It is worth pointing out that the DSM IV criteria for “Undifferentiated Somatoform Disorder” yielded higher estimates of the population at risk than do the criteria for DSM 5.

    His final suggestion is that physicians should use a “benign diagnosis.” We agree that the DSM IV diagnoses were highly stigmatizing. We hope that the DSM 5 approach will be less so, particularly with the de-emphasis of medically unexplained symptoms. DSM is hardly “a Bible.” DSM IV wasn’t, and DSM 5 won’t be either. The goal of the DSM is to accurately describe the patient’s presentation with the intention of providing helpful treatment. When a patient is better described by one diagnosis than another, it is sensible to use the one that is more accurate.

    The one thing we do agree with Dr. Frances on is the importance of caring for our patients. It is debilitating for individuals suffering from multiple persistent somatic symptoms and distressing preoccupations. The diagnosis of Somatic Symptom Disorder may be a logical next step in recognition and treatment of these patients.

    Competing interests: The authors are members of the DSM somatic symptoms workgroup
     
    Last edited: Jan 1, 2018
  18. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

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    (From previous PR threads on SSD)


    The Future of Psychiatric Diagnosis: Updates on Proposed Diagnostic Criteria for DSM-5 (Part III)


    Monday, May 7, at 9 a.m. – 12 noon, in Room 103B at the Pennsylvania Convention Center
    Chair: Darrel A. Regier, M.D., M.P.H. Co-Chair: David J. Kupfer, M.D.

    Presenters:

    1. DSM-5 Proposals for Somatic Symptom Disorders
    Joel E. Dimsdale, M.D.


    At the end of his presentation, Dr Dimsdale, Chair of the Somatic Symptom Disorders Work Group took a number of questions from the audience around proposals for what was at that point proposed to be termed, CSSD (Complex somatic symptom disorder).

    One questioner asked: Chronic fatigue syndrome has not been a part of the DSM-IV so far. Would there be any place for that in the DSM-5?

    Dr Dimsdale's response was: That's an important question. Chronic fatigue is an important, distressing, disabling condition - it is remarkably heterogeneous...remarkably heterogeneous. We feel that some patients with chronic fatigue would meet the criteria for CSSD - some wouldn't.

    Questioner responds: And what would be the cut off point...or what would be the criteria to include some and exclude others?

    Dr Dimsdale: Well, chronic fatigue is really almost a poster child for medically unexplained symptoms as a diagnosis - it's a very, very heterogeneous disorder and we would say that the B type criteria are defining. Now, I have friends with chronic fatigue - some of them would meet these criteria and some wouldn't - so if a person is unable to put this down or unable to get beyond the...who is just stuck with the B type considerations, we would consider that to be having CSSD.

    --------------------

    For testing the reliability of the proposed criteria for what was then proposed to be called, "CSSD", Dimsdale reported that three groups had been studied for the field trials:

    488 healthy people;

    205 people with cancer and malignancy (some patients in this group were said to have severe coronary disease);

    94 people in a "functional somatic" group (said to include "irritable bowel" and "chronic widespread pain"); it was not clarified whether that group had also contained CF or CFS patients and the data quoted is extracted from Dimsdale's slides and was unpublished data.

    Dr Dimsdale reported:

    that about 15% of the cancer and malignancy group met CSSD criteria if "one of the B type criteria" was required; if the threshold was increased to "two B type criteria" about 10% would meet the criteria for dual-diagnosis of cancer + "Somatic Symptom Disorder."

    For the 94 "functional somatic" study group, about 26% would be coded if one "B type" cognition was required; 13% were coded if two cognitions were required.

    About 7% of the "healthy" group were caught by the CSSD criteria.


    When the final draft for the DSM-5 was released, the proposed name for the new diagnosis had been changed from "CSSD" to "SDD".

    The number of "B type" criteria required to meet the diagnosis had also been changed - reduced from a requirement for two from the "B type" psychobehavioural responses to symptoms, to just one.

    For its third draft, rather than revise in favour of less inclusive criteria, Dimsdale's work group had lowered the threshold for a diagnosis of SSD, despite the considerable concerns expressed in stakeholders' submissions in the first and second review periods.
     
    Last edited: Jan 1, 2018
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  19. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

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    Extracts from:

    Submission from Suzy Chapman in the Third DSM-5 Comment and Review exercise
    (May 2 – June 15 2012)


    https://dxrevisionwatch.files.wordpress.com/2012/06/scdsm5sub7.pdf

    (...)

    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."


    "...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."
    [1]

    [1] Justification of Criteria - Somatic Symptoms, May 4, 2011 for second DSM-5 stakeholder
    review.

    (...)

    During the Q & A session at the end of Dr Dimsdale's APA Conference presentation, a
    questioner raised the issue that practitioners who are not clinicians or psychiatric
    professionals might have some difficulty interpreting the wording of the B type criteria to
    differentiate between negative and positive coping strategies.

    Dr Dimsdale was asked to expand on how the B type criteria would be operationalized and
    by what means patients with chronic medical conditions who devote time and energy to
    health care strategies to try to improve their symptoms and their level of functioning
    would be evaluated in the field by a very wide range of DSM users and differentiated from
    patients considered to be spending "excessive time and energy devoted to symptoms or
    health concerns"
    or perceived as having become "absorbed" by their illness and whose
    preoccupations were felt to be "disproportionate."

    By what means will the practitioner reliably assess an individual's response to illness
    within the social context of the patient's life and determine what should be coded as
    "excessive preoccupation" or indicate that this patient's life has become "subsumed" or
    "overwhelmed" by concerns about illness and "devotion" to symptoms?

    By what means would a practitioner determine how much of a patient's time spent
    "searching the internet looking for data" (to quote an example provided by Dr Dimsdale)
    might be considered a reasonable response to chronic health concerns within the context
    of this patient's experience?

    I am not reassured from Dr Dimsdale's responses that these B (1), (2) and (3) criteria can
    be safely applied outside the optimal conditions of field trials, in settings where
    practitioners may not necessarily have the time nor instruction for administration of
    diagnostic assessment tools, and where decisions to code or not to code may hang on
    arbitrary and subjective perceptions.

    (...)

    In his journal article Medically Unexplained Symptoms: A Treacherous Foundation for
    Somatoform Disorders?
    [2] Dr Dimsdale discusses the unreliability of "medically
    unexplained" as a concept and acknowledges the perils of missed and misdiagnosis:

    "...On the face of it, MUS sounds affectively neutral but the term sidesteps the quality of the
    medical evaluation itself. A number of factors influence the accuracy of diagnoses. Most
    prominently, one must consider how thorough was the physician’s evaluation of the patient.
    How adequate was the physician’s knowledge base in synthesizing the information obtained
    from the history and physical examination? The time pressures in primary care make it
    difficult to comprehensively evaluate patients and thus contribute to delays and slips in
    diagnosis. Similarly, physicians can wear blinders or have tunnel vision in evaluating
    patients.1 Just because a patient has previously had MUS is no guarantee that the patient has
    yet another MUS. As a result of these factors, the reliability of the diagnosis of MUS is
    notoriously low..."


    For DSM-5 then, the Work Group proposes to deemphasize "medically unexplained" as the
    central defining feature of this disorder group and instead, shift the focus to the patient’s
    cognitions – "excessive thoughts, behaviors and feelings" about the seriousness of
    distressing and persistent somatic symptoms which may or may not accompany diagnosed
    general medical conditions – and the extent to which "illness preoccupation" is perceived to
    have come to dominate the patient’s life.

    Dr Dimsdale concludes:

    "Patients present with an admixture of symptoms, preconceptions, feelings, and illnesses. The
    task of psychiatric diagnosis is to attend to the patient’s thoughts, feelings, and behaviors
    that are determining his/her response to symptoms, be they explained or unexplained."


    In proposing to license the application of an additional mental health diagnosis for all
    illnesses if the clinician considers the patient also meets the criteria for a "bolt-on"
    diagnosis of SSD, Dr Dimsdale and colleagues appear hell bent on stumbling blindly from
    the "treacherous foundation" of the "somatoform disorders" into the quicksands of
    unvalidated constructs and highly subjective, difficult to measure criteria.

    (...)

    Dr Dimsdale concedes his committee has struggled from the outset with these B type
    criteria but feels its proposals are "a step in the right direction."

    Patients deserve better than this; science demands rigor.

    In the absence of a substantial body of independent evidence for the SSD construct
    as a reliable, valid and safe alternative, I urge the Work Group not to proceed with its
    proposals for the reorganization of the "Somatoform Disorders" categories in favour
    of the status quo, or to dispense altogether with this section of DSM. There can be no
    justification for replacing one set of dysfunctional, unreliable and unsafe categories
    with another.



    [2] Dimsdale JE. Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? Psychiatr Clin N Am 34 (2011) 511–513 doi:10.1016/j.psc.2011.05.003
     
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  20. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

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    From another paper by Allen Frances on SSD, from June 2013:

    Frances A. DSM-5 Somatic Symptom Disorder.
    J Nerv Ment Dis. 2013 Jun;201(6):530-1. doi: 10.1097/NMD.0b013e318294827c

    http://www.ncbi.nlm.nih.gov/pubmed/23719325

    "I submitted to the work group a suggested tightening of their SSD definition
    that would go far to reduce the positive problem created by their loose criteria set.

    ...How were my suggestions received? I had a pleasant meeting
    with the head of the DSM-5 SSD work group. He seemed to understand
    the issues and readily offered to present them to his colleagues.
    The report soon came back that DSM-5 would go ahead with its own
    loose definition and include none of the more restrictive revisions I
    had suggested.

    "The DSM-5 criteria set was created by fiat and is based only on
    the personal opinions of a small group of experts, without support
    from any substantial body of research on the optimal definitional
    criteria, their reliability and validity, the impact of the new diagnosis
    on treatment decisions, and its practical utility. One thing is
    clear - consumers and consumer groups uniformly and passionately
    oppose the change for fear it will be stigmatizing, will result in inadequate
    medical workups, and will compromise access to services.
    Where does this leave us? I suggest that clinicians not use the
    loosely defined and fatally flawed SSD diagnosis."



    If Dimsdale had not agreed with the consensus opinion of his 10 member SSD Work Group, he could have stood down. But he did not. He signed off on a set of criteria for which the threshold for meeting the diagnosis had been even further reduced.
     
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