sounds like Fink et al are the most dangerous group at the moment
Fink, Rosendal, Henningsen are seeking the roll out of further BDS clinics in Denmark and (with Creed) have discussed at EACLPP workgroup meetings whether the MH chapter of ICD-11 would be a better place to locate the so called FSSs:
"...Organisation of services: Splitting or lumping? We are in danger of having
separate clinics for chronic fatigue syndrome, chest pains, fibromyalgia
etc etc. we need to develop best practice - and join up these different
clinics and get them more centrally placed on the agenda - make them more
visible to all specialists...
...We should find out whether the WHO group for classification of somatic
distress and dissociative disorders will provide a better diagnostic system
for these disorders."
Source: Notes from EACLPP Workgroup meeting in Budapest July 2011:
http://www.eaclpp.org/tl_files/content/eaclpp/Working%20Groups/EACLPP_WG_Medically_Unexplained_Symptoms_Budapest_2011.pdf
------------------------------
Dr Rosendal is a member of the
ICD-11 Primary Care Consultation Group (chair, Prof Sir David Goldberg). She is also a committee member of WONCA.*
*Dr Marianne Rosendal (Department of Public Health, Aarhus University), who has published with Prof Per Fink, is the European representative on WONCA’s International Classification Committee. The vice-chair of the PCCG is Dr Michael Klinkman, a GP who represents WONCA (World Organization of Family Doctors). Dr Klinkman is current convenor of WONCA’s International Classification Committee (WICC) that is responsible for the development of ICPC-2.
When the key Lam et al paper was published in 2012, Dr Rosendal's influence was evident.
The proposals of the
Primary Care Consultation Group (PCCG) presented a disorder construct that had strong congruency with Fink et al's BDS but which the PCCG proposed to call
"Bodily stress syndrome" (BSS).
In 2012, the PCCG's tentative criteria proposals could not be described as a "pure" BDS disorder construct since the criteria had included some SSD like psychobehavioural features. But they drew heavily on the BDS construct and criteria.
However, the term and disorder construct that has been entered into the ICD-11 Beta draft is
"Bodily distress disorder" (BDD) which is a divergent disorder construct, conceived by the
ICD-11 Expert Working Group on Somatic Distress and Dissociative Disorders (S3DWG) working group.
The S3DWG's
Bodily distress disorder (BDD) construct is the term and disorder concept that has been entered into the ICD-11 Beta drafting platform
since 2012. In 2014,
Definitions were inserted for the three, coded, severity specifiers.
As conceptualized by the S3DWG,
Bodily distress disorder with three severity specifiers (Mild; Moderate; Severe) is proposed to replace the seven ICD-10
Somatoform disorders categories between F45.0 to F45.9, and also subsumes ICD-10's F48.0
Neurasthenia.
The Definition and characterization for the S3DWG’s Bodily distress disorder is drawn from the BDD disorder descriptions in the key Creed, Gureje (2012) paper:
Emerging themes in the revision of the classification of somatoform disorders (behind a paywall).
In the context of ICD-11 usage, the S3DWG's
“Bodily distress disorder” has stronger conceptual alignment and criteria congruency with DSM-5’s
Somatic Symptom Disorder and poor conceptual and criteria congruency with Fink et al’s (2010)
“Bodily Distress Syndrome.”
Fink et al's BDS and DSM-5's SSD are fundamentally different disorder constructs; they have different
characterizations, very different criteria and capture different patient populations.
There is immediate potential for confusion, here, because the terms “Bodily distress disorder” and “Bodily distress syndrome” are already used interchangeably, in the field, by researchers and clinicians when referring to Fink et al's, already operationalized, BDS.
I have proposed to ICD Revision that consideration should be given to changing the proposed disorder name for the S3DWG’s disorder construct and this has also been discussed with ICD Revision's, Dr Geoffrey Reed.
There may be intellectual property issues around ICD-11 using the DSM-5 disorder name
"Somatic symptom disorder" for its proposed replacement construct for the ICD-10
Somatoform disorder categories which may preclude use of an identical criteria set.
But those with a good understanding of the already operationalized BDS criteria and who have scrutinized the Lam et al (2012) paper will note that the BSS criteria (as proposed in 2012) draw heavily on the Fink et al, 2010, BDS construct and criteria).
They will grasp that the BDD disorder construct, as defined by the S3DWG working group in the Beta draft and in the paper by Creed, Gureje (2012), describes an SSD like construct.
How is the S3DWG’s BDD conceptualized?
The S3DWG’s BDD eliminates the requirement that symptoms should be “medically unexplained” as the central defining feature.
Instead, the focus is on identification of positive psychobehavioural responses (excessive preoccupation with bodily symptoms, unreasonable illness fear, frequent or persistent healthcare utilization, activity avoidance for fear of damaging the body) in response to any (unspecific) persistent, distressing, single or multiple bodily symptom(s), and resulting in significant impairment of functioning or frequent seeking of reassurance.
The diagnosis makes no assumptions about aetiology, and in
“[d]oing away with the unreliable assumption of its causality, the diagnosis of BDD does not exclude the presence of depression or anxiety or of a co-occurring physical health condition.”
The S3DWG’s BDD has
no requirement for symptom counts, symptom patterns or symptom clusters from body or organ systems.
All of which describes a disorder framework with
good concordance with DSM-5
Somatic Symptom Disorder (SSD).
According to the disorder descriptions, BDD’s three severity specifiers are proposed to be characterized on the basis of the extent to which psychobehavioural responses to persistent, distressing bodily symptom(s) are perceived as excessive or maladaptive, and on the degree of impairment,
not on the basis of the number of symptoms, or symptom patterns or clusters, or number of body or organ systems affected.
In comparison, psychobehavioural responses
do not form part of Fink et al’s (2010)
Bodily Distress Syndrome criteria. Fink's BDS’s criteria, and its two severities are based on symptom patterns from body systems (a BDS Modest, single-organ type and a BDS Severe, Multi-organ type).
The S3DWG's BDD proposals appear to have good alignment with the DSM-5's SSD construct, facilitating harmonization between DSM-5 and ICD-11. Being based on
positive psychobehavioural features, BDD should not present problems for placement within a mental disorder chapter.
According to ICD's Dr Reed (July 2014):
ICD Revision are currently involved in testing the primary care group's proposals in this area in primary care settings around the world, in part to compare how they work with the proposals of the Working Group on Somatic Distress and Dissociate Disorders. Whether the primary care proposal ends up capturing specific groups of patients in primary care who are likely to have underlying medical conditions will certainly be one of the issues for examination and further discussion...
Dr Reed also said that further modifications of the proposals in the areas of interest to me will be based on data, and justifications made available. In due course, ICD Revision will make more detailed diagnostic guidelines for all Mental and Behavioural Disorders areas available for review and comment before they are finalized, but they are not yet ready to do that and that he will notify me when that occurs, but he anticipated this will be before the end of the year.
So,
two working groups and
two sets of divergent proposals for a potential replacement for ICD-10's
Somatoform disorders and it is the proposals of the S3DWG for an SSD like "BDD" that are entered and defined in the Beta draft - not a BDS like construct or a hybrid of SSD and BDS.
I shall be expanding on these two sets of proposals in
Part 3 of my report.
