DSM-5 proposals for Somatoform Disorders revised on April 27

[beaker]

Thank you for your continued hard work on this issue. It is beyond my brain power, and I know I am not the only one.

 

[Dx Revision Watch]

Thank you for your continued hard work on this issue. It is beyond my brain power, and I know I am not the only one.

You're welcome, beaker.

According to David Kupfer, MD, who chairs the DSM-5 Task Force, "After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable." Source: Psychiatric News | May 4, 2012


Between the posting of the third draft on May 2 and the signing off on the final texts which will need to be with the printers in December for preparation for a May publication, there will have been discussions at the APA's annual conference where each work group chair will have presented results of the field trials; review of responses received during this final stakeholder comment period; completion of the writing of the texts that accompany criteria and approval of the draft by the Task Force and by APA governing body.

Although the third draft will remain posted on the DSM-5 Development website, it does not look from David Kupfer's comments above as though any further changes to criteria and disorder descriptions that might be made between now and the near final draft will be posted on the DSM-5 Development site.

So we may not learn what the final decisions are until the DSM-5 is published, next May - assuming, that is, that the Task Force and work groups can complete the remaining work to schedule and are not persuaded to delay publication while further field trials are run (a second round of field trials that had been scheduled for last year were abandoned by the APA because the timeline was slipping).


The DSM-5 will be available as a paid for print edition. There are also plans for an online version DSM-5.x that can be corrected and updated more readily than print editions. This is likely to be accessed via subscription since the DSMs are a major income generator for the APA and they ain't going to give this new edition away for free. In contrast, ICD-11 will be available in both print versions and free access electronic versions, as will the forthcoming US specific ICD-10-CM.


There are still no PDFs on the DSM-5 Development site for the two "Disorder Descriptions" and "Rationale/Validity" documents that accompanied the first and second drafts. It isn't known whether the intention had been to post new documents which would reflect the most recent proposals but these are not ready. The previous documents have been removed.

Anyone coming fresh to the proposals won't have access to those documents (which are still archived on my site). I'm keeping a watch on the site in case they are uploaded during the comment period. I will also write to the Media and Communications Office, today, and enquire whether the SSD Work Group is intending to publish updated PDFs during the stakeholder comment period.

 

[Dx Revision Watch]

Report by Deborah Brauser for Medscape Medical News from the APA's annual conference at which field test results were presented.


http://www.medscape.com/viewarticle/763519

From Medscape Medical News > Psychiatry

DSM-5 Field Trials Generate Mixed Results

Deborah Brauser


"May 8, 2012 (Philadelphia, Pennsylvania) Preliminary results are mixed for the recently completed field trials for the upcoming Diagnostic andStatistical Manual of Mental Disorders, Fifth Edition (DSM-5), according to the first public presentation of the findings here at the American Psychiatric Association's (APA's) 2012 Annual Meeting."

"Diagnostic criteria for autism spectrum disorder, posttraumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD) in children were found to be very reliable."

"Conditions that did not do well included major depressive disorder (MDD), in adults and in children, and general anxiety disorder (GAD)..."


"...Members of the task force said they hope to publish the full results "within a month." However, the third and final public comment period for the manual opened last week and ends on June 15. Although the entire period is 6 weeks long, the public may only have 2 weeks to comment after the publication of the field trials' findings."

"From all accounts, the manual is still on track for publication right before next year's APA Annual Meeting in San Francisco."

"As reported by Medscape Medical News, the field trials began in the fall of 2010 to test newly recommended diagnostic criteria in both academic and "routine" clinical settings."

"A total of 11 academic sites 7 that focused on adults, 4 that focused on children/adolescents were involved in the process, which included a baseline assessment by a clinician followed by a second assessment within 2 weeks by a different clinician to test criteria reliability."

"In addition, volunteer clinicians, including psychiatrists, psychologists, and social workers from smaller, clinical settings were included. These participants went through initial Web-based training and then selected and evaluated 2 patients each."

"A total of 665 children and adolescent patients and 1593 adult patients were included in the field trials."

"No previous field trial had such a sophisticated design. And it has resulted in more statistically significant data for specific disorders," said Dr. Regier."

"The current DSM-5 field trials, as well as field trials for past manuals, use Kappa score as a statistical measure of criteria reliability. A Kappa score of 1.0 was considered perfect, a score of greater than .8 was considered almost perfect, a score of .6 to .8 was considered good to very good, a score of .4 to .6 was considered moderate, a score of .2 to .4 was considered fair and could be accepted, and a score of less than .2 was considered poor."

---------

The field trials on CSSD were held at Mayo. According to one of several tables in Ms Brauser's report the following data were released for "Complex somatic disorder"



Complex somatic disorder

DSM-5 .60 (.41 - .78)
DSM-IV
ICD-10 .45
DSM-III .42

Since Complex Somatic Symptom Disorder is a newly proposed category for DSM-5 which absorbs the existing DSM-IV categories

Somatization Disorder
Hypochondriasis
Undifferentiated Somatoform Disorder
Pain Disorder

and does not exist in ICD-10 nor did it exist in DSM-III. It's unclear what category data have been used for the kappa comparisons for ICD-10 and DSM-III.

 

[Dx Revision Watch]

SSD Work Group Chair, Joel Dimsdale, says "Chronic fatigue is really almost a poster child for medically unexplained symptoms" at a presentation by Joel E. Dimsdale, MD, at the DSM-5 Track at the APA's Annual Conference in Philadelphia.

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.

 

[Dx Revision Watch]

http://www.medpagetoday.com/MeetingCoverage/APA/32619

MedPage Today​

​

DSM-5: What’s In, What’s Out​

​

John Gever, Senior Editor, MedPage Today | May 10, 2012​

​

…The final drafts are to be completed by August, then they must be approved by a scientific review committee and the task force leadership, and finally by the APA’s governing bodies.​

​

"Kupfer said the final version has to be completed by December, when it’s set to go to the printer. Its formal release is planned for the APA’s annual meeting next May in San Francisco.​

​

Here’s a brief overview of the changes you can expect…​

​

WHAT’S OUT​

WHAT’S IN (or STILL IN)​

WHAT DIDN’T MAKE IT​

WHAT TO LOOK FORWARD TO​

 

[Esther12]

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.

lol - they really don't seem to mind not knowing what they're talking about, but still placing themselves in positions of expertise and authority over the cognitions and minds of others. How 'pragmatic' of them.

edit: Here are the 'B type considerations':

B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.

(1) Disproportionate and persistent thoughts about the seriousness of ones symptoms.

(2) Persistently high level of anxiety about health or symptoms

(3) Excessive time and energy devoted to these symptoms or health concerns

All of those criteria are so subjective, and dependent upon the 'experts' views on the cause and seriousness of the patient's symptoms. Any insurance company who wanted to present a claim as being based on psychological factors would be able to find a psychiatrist happy to play along with these sorts of criteria.

Surely he should have had better answers to those basic questions.

 

[Esther12]

Thanks for all your work Suzy. You should edit your work together as a digital book at some point... you must know the topic really well, and it's gotten some mainstream coverage and interest.

 

[SOC]

What on earth is a mental illness if it is not dysfunction of brain chemistry etc. I mean last stages of syphilis is just that - who needs psyches to ponder as understanding of viral infections/treatments and all things affecting the brain grow.

There are conditions which are caused strictly by dysfunction of brain chemistry, but there are also conditions that involve disordered thinking. The first group actually belong under neurology, IMO, but historically -- before we understood brain chemistry -- these illnesses were believed to be 'mental' illnesses, that is, illness of the thinking mind. Psychologists and psychiatrists don't want to let go of those patients because they are a large segment of their population, so they try desperately to keep them under their control.

There are also people who, because of poor upbringing, trauma, or even trauma of illness, including neurochemical dysfunction, have developed thought processes which may have allowed them to cope with the difficult situation, but are dysfunctional in normal life. This group clearly belongs in psychology and psychiatry and talk therapy can do a lot of good for these patients.

For example, endogenous depression is caused by neurochemical disorders while exogenous depression is caused by conditions external to the individual -- trauma, poor upbringing, etc.

That isn't to say that people can't have both a neurochemical dysfunction and disordered thinking. In fact, as with any stressful and poorly understood illness, having a neurochemical dysfunction can alter one's perception of the world in ways that might not be ultimately functional. Similarly, it is reported that continuous dysfunctional thinking can affect neurochemistry. However, I have some doubts about subject selection in this research, just like I do in ME/CFS.

I am fairly confident that ME/CFS can (not automatically does) cause disturbances in neurochemistry that result in feelings of depression, anxiety, and other mood disorders. This kind of physical dysfunction can be treated with physiological intervention -- medication, not talk therapy or efforts to change perceptions.

On the other hand, how we cope with illness, including neurochemical dysfunction, can determine whether we develop disordered thinking as well. For example, you can feel anxious and understand that it's a neurochemical problem and not the result of a life situation and react accordingly. Or, you can feel anxious and act on this as if it was the genuine result of a life situation when it's not and create dysfunctional situations for yourself. Talk therapy can help with that, but it will not change the underlying physical dysfunction.

Where I have a lot of trouble with psychology and psychiatry, including the DSM, is where they start claiming that genuine physical conditions are the result of disordered thinking. That's been disproved over and over -- MS as "hysterical paralysis", ulcers as a "stress induced illness", etc, but they still hang onto it much to the detriment of people with poorly understood physical illnesses.

We should care a lot about what's in the DSM. This is the document our doctors, not just psychologists, are going to use to claim that our illness is the result of disordered thinking rather than genuine physical illness whenever they don't immediately understand the cause. The wrong info in the DSM could be fatal for us.

 

[Dx Revision Watch]

Only limited access to these pages is available to non subscribers but I note that Joel E Dimsdale, MD, is the Section Editor for the entries for somatization:

Link 1

Link 2

MUS

Link 3

 

[alex3619]

Hi SOC, in reply to post 49, they still claim peptic ulcers are stress related or similar. Yes, they acknowledge H. pylori, but since not everyone with this pathogen gets peptic ulcers, it must be H. pylori and stress etc. causing it. No matter what people say, what discoveries are made, they keep changing their claims and will not give it up until its been thoroughly trashed in scientific circles. Since most scientists do not engage with their models there is simply not enough criticism.

Its like a small town with a one candidate election for mayor, and the candidate is borderline delusional. But with no competition from inside the town ... meanwhile commentators in nearby towns are shaking their heads but not getting involved because its not their town after all.

Bye, Alex

 

[SOC]

They just won't let go, do they?

I suspect that it is predominantly those members of the medical profession who are afraid to say they don't know and those of the psychobabble persuasion who need to feel superior to mere mortals -- the "I have to know better than patients, no matter what" people. They may not be the majority in the professions, but I suspect their insecurity makes them very insistent and very vocal. And heaven forbid they would actually have to admit they were ever wrong.

Meanwhile, as you say, other doctors and psychologists are sitting in "the next town over" thinking it's not their problem and they don't have time to fight about it.

I'll chime in, too, and say that I think there are excellent psychiatrists and psychologists out there. The issue is not the profession itself, imo, but the territorial creep that is allowing those so inclined to improperly apply psychology to physiological conditions. It's a matter of not giving them infinite power, which all these thinking-yourself-sick theories do. They essentially give the doctor or psychologist the power to say, "I think you're making it up, therefore you are."

"Unlimited power is apt to corrupt the minds of those who possess it"- William Pitt the Elder, Earl of Chatham and British Prime Minister from 1766 to 1778

 

[Dx Revision Watch]

Allen Frances, who had chaired the DSM-IV Task Force has an Op-ed piece published in NYT, today:


New York Times
Op-Ed Contributor

http://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html

Diagnosing the D.S.M.

Allen Frances | May 11, 2012

“…All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts. Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.

"Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots…”

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

Benedict Carey, NYT, May 8:

New York Times

http://www.nytimes.com/2012/05/09/health/dsm-panel-backs-down-on-diagnoses.html

Psychiatry Manual Drafters Back Down on Diagnoses

Round up of recent DSM-5 news coverage, including two Reuters news alerts on Dx Revision Watch in this post

 

[Enid]

I haven't been able to follow through the ins and outs of this battle but this sounds like great news in the long saga.

 

[Dx Revision Watch]

A reminder that this third and final stakeholder review and comment period is scheduled to close on June 15.​

On May 17, APA added the following statement to the home page of the DSM-5 Development site.

​

APA Position Statement on DSM-5 Draft Diagnostic Criteria

The official position of the APA on draft DSM-5 diagnostic criteria is that they are not to be used for clinical or billing purposes under any circumstances. They are published on the www.dsm5.org Web site to obtain feedback on these preliminary DSM-5 Task Force proposals from mental health professionals, patients, and the general public. They have not received official reviews or approval by the APA Board of Trustees and will not be available for clinical use or billing purposes until May 2013.

Two articles in this week's online and print editions of New Scientist.

The first report, by Peter Aldhous, quotes Allen Frances, MD, who had chaired the development of the DSM-IV; APA research director and DSM-5 Task Force Vice Chair, Darrel Regier, and Dr Dayle Jones who is tracking DSM-5 for the American Counseling Association, on DSM-5 field trial kappa results and the relegation of Attenuated psychosis syndrome and Mixed anxiety/depression to the DSM-5 appendix.

This article is behind a paywall or a subscription to the print edition.

New Scientist 19 May 2012

Page 6 print edition

THIS WEEK/MENTAL HEALTH

Psychiatry's new diagnostic bible is creating headaches for doctors and patients alike
Online title Trials highlight worrying flaws in psychiatry 'bible'

Peter Aldhous

Diagnosis: uncertain
HOW reliable is reliable enough?



The second article, "OPINION 'Label jars, not people", by James Davies, is accessible on the New Scientist website without payment of print edition subscription.

New Scientist 19 May 2012

Page 7 print edition

OPINION | James Davies

James Davies is a senior lecturer in social anthropology and psychotherapy at the University of Roehampton, London

'Label jars, not people'

"LABEL jars, not people" and "stop medicalising the normal symptoms of life" read placards, as hundreds of protesters - including former patients, academics and doctors - gathered to lobby the American Psychiatric Association's (APA) annual meeting.

The demonstration aimed to highlight the harm the protesters believe psychiatry is perpetrating in the name of healing. One concern is that while psychiatric medications are more widely prescribed than almost any drugs in history, they often don't work well and have debilitating side effects. Psychiatry also professes to respect human rights, while regularly treating people against their will. Finally, psychiatry keeps expanding its list of disorders without solid scientific justification...
Read full article

 

[Enid]

Great news ! - do the psyches think everyone else is an idiot.

 

[Valentijn]

I can't read much of what you wrote, Suzy ... most text colors don't work against a dark background.

 

[taniaaust1]

I can't read much of what you wrote, Suzy ... most text colors don't work against a dark background.

Valentijin ... Im using the dark background. If you highlight the post.. it will make those very dark not readable letters white.

 

[taniaaust1]

SSD Work Group Chair, Joel Dimsdale, says "Chronic fatigue is really almost a poster child for medically unexplained symptoms" at APA Annual Conference

In the next few days, I plan to post further notes on the presentation by Joel E. Dimsdale, MD, at the DSM-5 Track at the APA's Annual Conference in Philadelphia.

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 a brief presentation, Dr Dimsdale, Chair of the Somatic Symptom Disorders Work Group took a number of questions from the audience around proposals for CSSD and Conversion 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.

thanks Suzi for sharing that... it truely looks like like ME/CFS people are going to end up in a world of trouble (far worst) situation due to all this. The sicker you are hence the more you are symptom focused.. the more you may fit their catagory of mental health disorder.

People think things are bad enough now, it could actually get far worst if ME International definition is not generally accepted by most doctors and CFS gets placed thou under a new name (so all the ME people too) , into their mental health manual for the first time.

I hope Im wrong but I think the ME/CFS situation is about to became all the worst.

 

[Don Quichotte]

You have nothing to worry about. If the DSM-5 is accepted and taken seriously, every human being on this planet (and possibly some aliens as well) will have at least one psychiatric diagnosis during his/her life-time and most will have quite a few.
In fact if you will not fit any of the DSM-5 categories, it would be quite likely that you are not a human.

I find it ridiculous that people use words like- believe and feel, when discussing what is supposed to be accurate, reproducible and scientific.

Responsible psychiatrists are also concerned about the DSM-5

http://www.nejm.org/doi/full/10.1056/NEJMp1202555

Psychiatrists would start moving toward the day when they address psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations as products of nature to be comprehended not simply by their outward show but by the causal processes and generative mechanisms known to provoke them. Only then will psychiatry come of age as a medical discipline and a field guide cease to be its master work.

And psychiatry is very far from that and can not leap over this enormous gap by turning the field into "pseudomedicine".

 

[Dx Revision Watch]

I can't read much of what you wrote, Suzy ... most text colors don't work against a dark background.

As some readers are using different coloured backgrounds and having problems viewing coloured fonts, and since I can't predict how text is displaying to those who are using coloured backgrounds, I won't use any coloured text in future postings.