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