The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally illBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1580 (Published 19 March 2013) Cite this as: BMJ 2013;346:f1580
All rapid responses
Chillingly accurate prediction: The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill
This BMJ article by Allen Frances published back in March 2013, with its own substantial collection of very interesting responses, has come to attention recently.
At that time Allen Frances warned that the DSM-5 definition of somatic symptom disorder "may result in inappropriate diagnoses of mental disorder and inappropriate medical decision making". The new category extended the scope of mental disorder classification by eliminating the requirement that somatic symptoms must be “medically unexplained”. In DSM-5, the focus shifted to “excessive” responses to distressing, chronic, somatic symptoms with associated “dysfunctional thoughts, feelings, or behaviours.”
We are now very clearly seeing evidence of the applications of the DMS-5 Somatic Symptom Disorder (SSD), often still referred to as Medically Unexplained Symptoms (MUS) across the NHS system. It is utterly chilling to realise just how pertinent the 2013 prediction was - and how it is now becoming embedded in the context of 'modernising' NHS services: STPs, cost-cutting, shared care, IAPT and so on.
In recent months there have been a number of articles in the BMJ and in the BJGP on the topic, some of which I (and others) have commented on, for example: http://www.bmj.com/content/356/bmj.j268/rapid-responses.
Please may I draw particular attention to these two patient responses to a BJGP comment by Rachel Pryke ('Why are MUS conflated with heartsink?') relating to an active ongoing BJGP discussion on the topic of SSD/MUS: http://bjgp.org/content/67/659/252.1/tab-e-letters.
These current discussions are immensely important and alarming. Something is going horribly wrong when it is becoming apparent that previously healthy patients are being seriously harmed and made very unwell by medicines 'taken as prescribed' - and are then being dismissed/described as troublesome heartsink patients who display “excessive” responses to distressing, chronic, somatic symptoms with associated “dysfunctional thoughts, feelings, or behaviours.”
These patients are finding their medical records and referral letters - and even reports to MHRA - couched in phrases such as "the patient believes" and "the patient thinks". They are also being labelled with "attention seeking behaviours" and assorted "personality disorders" so as to discount and deny credibility of their very real experiences and immensely distressing functional symptoms.
There feels to be something distinctly Orwellian about this state of affairs.
Competing interests: No competing interests
It is interesting that the concepts underpinning the proposed diagnosis of "somatic symptom disorder" have caused such furore, heightened emotions and confusion, as is evident in the responses.
When I first saw this term, I was completely underwhelmed. On the face of it this seems to me a very bland and soulless term, telling us little about what causes the problem, what the patient experience is and what would be the correct treatment. It does not even have the first name or second name of the person that described it, there is no judgemental tone (cf "conversion syndromes)- it can in many ways be seen to epitomise the failure of diagnostic systems in "conditions of uncertain aetiology".
Is this a "take over bid" by psychiatry so that all known conditions will have a psychiatric sub-classification? I hope not, believe me as a practising psychiatrist I have more than enough clinical work without an exponential expansion of our remit. Is this a long overdue attempt to make sense of a very confused and murky area in the hinterland between "medicine" and "psychiatry"? If so, I like many other remain just as confused and in awe of the amount of work still be done in understanding these significant health problems. I am not sure about the subtext regarding the pharmaceutical industry and their role in
promoting new diagnoses and their treatment. I suspect not, the new term is just not catchy enough or marketable in my view.
I feel that the core issue is that probably neither "psychiatry" or "physical medicine" have perfect diagnostic systems. Sometimes the proposed physical markers of a medical condition turn out to be wrong, there are too many exceptions, or new research challenges the fundamentals of diagnosis. Psychiatry has to rely on narrative, clinical skills of the assessing clinician in the absence of physical markers. Both psychiatric and physical disorders are real, with real suffering affecting real people.
Reading the responses, I was struck by the very real fear that people have expressed of inapproriate labelling, I think this goes beyond "perceived stigma" of having such a diagnosis. My hunch is that this is more related to the understandable worry that treatment is not available, or that inappropriate and ineffective treatment might be offered.
Finally, when looking at the debate and correspondence, I was struck by the analogy of a well-known TV series, where the mobile chemist is trying to refine his wares by using a scientific method to produce high quality drugs. The drugs offer the promise of greater purity, efficacy and reliability. However, they are still dangerous in the wrong hands, have the same problems and are associated with a rather dodgy distribution scene.
I would like to offer the possible aphorism which helps guide me through practice when facing diagnostic uncertainty. "Sceptical about diagnoses, but never about patients".
Competing interests: The views expressed are mine alone and do not necessarily represent those of my employers.
As a Moderator on the support group~Living with Trigeminal Neuralgia, I am deeply concerned about "The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill ". I fear that this will lead to withdrawal of appropriate treatments and wrongly labeling many patients who already have too much to bear. I have corresponded with thousands of chronic pain patients. I have never had the slightest inkling that any one of them is mentally ill. Depression caused by chronic pain is common, who in permanent severe pain would not have depression? But I do not believe that they ONLY have depression. Please do all you can to stop this grave injustice. As a sufferer myself, I strongly oppose DSM-5.
Competing interests: No competing interests
If being "overly concerned" about having, let's say, cancer, is now to be considered a mental disorder, then what in the minds of psychiatrists would be considered a healthy response a bad diagnosis? Joy? Is the "new normal" going to require that every single natural human response to misfortune be replaced by a bland, and most likely drugged, state of emotional complacency? This is a brave new world, indeed.
Competing interests: No competing interests
The last paragraph in Steven A King's response - about not understanding why genital area pain has been considered psychological - really cheered me up.
Any doctor or psychiatrist who would try that on me would get blasted. Left to tear up during first childbirth, now having a prolapsed uterus which brings about frequent UTIs and other problems, causes a lot of genital area pain and discomfort and anyone trying to blame this on anything but medical reasons would be way out in left field.
Pain "down there" started occuring a long time before the prolapse was complete, probably because it sets in during the process of prolapsing - although I state once again that I have no big diploma. Of course, one has to remember how women's pain is too often labeled as hysterical!
Competing interests: No competing interests
Being just a very ordinary person with no big diploma, one thought has occurred to me as I have followed what is happening with the DSM-5 and SSD.
We live in a time when there is a big push for more public acceptance of psychiatric disorders - which is okay - because the psychiatric label is very bad in many ways: with family, with employers, with insurers, with the whole other medical field.
Could creating SSD have something to do with ensuring that almost EVERYONE out there has a psychiatric label, at one time or other, or always? This would make it a free-for-all for pharmaceutical companies and for insurers who do not cover psychiatric disease as a disability.
Competing interests: No competing interests
Controversy over SSD is indeed about where the line between medicine and psychiatry should be drawn, because SSD continues to play the same primarily medical role as its former cousins, regardless of the new inclusiveness. SSD is centrally an explanation for physical symptoms, one physicians will look to when faced with medical diagnostic challenges.
While it’s right to be concerned that this new line in the sand will generate needless psychiatric care, the real problem with SSD is really much more grave: it sanctions refusal to face the seriousness of the risk of error, the problem of medical harm that results when patients with medical problems are mistakenly denied medical care.
In medicine, differential diagnosis is the strongest sign of commitment to minimizing error. If it’s not visible throughout the process, the very notion of diagnosis begins to lose its meaning. It is highly problematic that the DSM-V eliminates the reminder that diagnoses of SSD should be made through this rigorous process, meeting the very same standards required for any other explanation of physical symptoms – but the DSM-V does not create this problem. Lack of concern in psychiatry about patients whose medical symptoms are mistakenly diagnosed as psychiatric passively mirrors a lack of concern about those patients in the medical community.
In medicine, resistance to the notion of error in somatoform diagnoses is so thoroughly pervasive that there exist no precautions of any kind, no protocols, and no forms of oversight to ensure that as few patients as possible are mistakenly diagnosed. It is absurd to pretend that physicians are any less tempted by answers that involve less work than any other human beings, or any less drawn to answers that free them from the specter of failure, but when it comes to somatoform diagnoses this pretense is endemic.
Given that physicians are not psychiatrists, isn’t it reasonable to expect that the reverse would be true – that the problem of potential error in diagnoses of SSD would receive more attention than the problem of error with other diagnoses? Given that patients with physical symptoms explained by diagnoses of SSD are denied further medical care for those symptoms, isn’t it reasonable to expect that the problem of potential error would be paramount in all discussions of SSD?
This oversight is so very serious, and yet so insistently silent, that we’ve grown accustomed to accepting it – so much so that the APA comfortably eliminates all the medical specifics, leaving physicians entirely free to make use of the label of SSD in whatever ways they happen to prefer. While removing any checklist inevitably increases risk of error, the APA finds no cause to even mention the physical suffering and threat of harm created when medical symptoms are mistakenly diagnosed as psychiatric, tending instead to the urgent matter of emotional struggles for “the many people who are suffering with both SSD and another medical diagnosis”.
Silence about the problem of error can only be the result of ignorance about the numbers of patients who present their physicians with truly unusual medical problems – with the hoof-beats of zebras rather than horses. There are nearly 30 million people in this country with rare diseases. Otherwise put, 1 in 10 Americans head to their doctors’ offices with diseases likely to be unfamiliar, diseases almost sure to lead to diagnostic confusion. Rare disease patients outnumber cancer patients by more than 2 to 1, even including all those whose cancer is now in remission. It is tough to quantify the role somatoform diagnoses play in the average 7-year lag to diagnosis of rare disease, but related statistics are immensely worrisome.
Though autoimmune disease is not rare, a recent survey revealed that 45% of patients with autoimmune disease have battled mistaken somatoform diagnoses. No doubt those 10.5 million patients found their genuine medical symptoms “very distressing, resulting in significant disruption of functioning”, meeting the first criterion for SSD. Moreover, in the need to find relief, all 10.5 million would have proceeded to display “excessive and disproportionate thoughts, feelings and behaviors regarding [their] symptoms”, justifying their mistaken diagnoses in a way that meets the second criterion.
Figures like these are common and should be central to any discussion of SSD. If physicians resort to these kinds of diagnoses so freely and so frequently as to mistakenly deny medical care to almost half of all patients with autoimmune disease, what’s happening to patients with rare diseases? Does the medical community have no ethical obligation to try to protect the 30 million people whose diseases are so unfamiliar as to positively invite the label of “medically unexplained”? Does removal of that phrase from the DSM somehow eliminate the APA’s own ethical obligation to these 1 in 10 Americans?
Because SSD will always be easier and less threatening for the physician than continued investigation of unusual or confusing symptoms, and because error consigns patients in need of medical care to potential lifetimes of untreated suffering and threat of harm, true credibility for SSD must be hard earned, rigorously earned, earned with humility about error and with visible commitment to protecting patients from it.
The history of silence in the medical community about the problem of error in somatoform diagnoses should feel to us not like a gentle warning, but like a blaring brass band. It tells us that when it comes to the border between medicine and psychiatry, the medical community has a pathology of its own, a glaring lack of maturity that allows the field to accept the risk of error without ever having considered the severity of its potential harms, or any systematic measures for reducing the risk of those harms. The medical community has not earned the keys to the kingdom of the borderlands between medicine and psychiatry. For the APA to hand them over so freely, with so little guidance and with such thorough disregard for the suffering of misdiagnosed patients, is negligent in the extreme.
1. American Psychiatric Association: www.psychiatry.org/File%2520Library/Practice/DSM/DSM-5/DSM-5-Somatic-Sym...
2. NIH Office of Rare Disease Research: http://rarediseases.info.nih.gov/AboutUs.aspx
3. American Cancer Society: http://www.cancer.org/cancer/cancerbasics/cancer-prevalence
4. In Need of Diagnosis, Inc: http://www.inod.org/home0.aspx
5. American Autoimmune Disease Association: https://www.aarda.org/infocus_article.php?ID=15
6. National Institute of Environmental Health Sciences: http://www.niehs.nih.gov/health/materials/ autoimmune_diseases_508.pdf
7. American Psychiatric Association: www.psychiatry.org/File%2520Library/Practice/DSM/DSM-5/DSM-5-Somatic-Sym...
Competing interests: Dr. O'Leary is author of the forthcoming book, Patient, a memoir exposing the problem of denial of care for rare disease patients. She is also Executive Director of The Sneddon's Foundation.
As a physician who trained in both psychiatry and pain management and chaired the DSM-IV and DSM-IV-TR committees on Pain Disorders, I have been very concerned about subsuming these diagnoses under the new Somatic Symptom Disorder diagnosis in DSM-5. During both periods when comments on DSM-5 were allowed I expressed these concerns to the committee overseeing this diagnosis and later to Dr. Dimsdale personally.
I believe that, at least as regards to how it handles pain, the new diagnosis is a step in the wrong direct and the rationale for making the proposed changes are incorrect. I don't know how any one could determine what are "excessive thoughts, feelings and behaviors" required for this diagnosis for example for a patient with cancer pain or one who has been disabled by chronic pain as we have absolutely no idea as to what would be a normal or expected response to these problems. From my experience such thoughts, feelings and behaviors would probably be more a reflection of the mismanagement of pain experienced by many patients rather than psychological issues of the patients themselves. Furthermore, its indication that this diagnosis fits on a continuum with conversion and factitious disorders strongly suggests the pain involved isn't "real." In fact, pain that is secondary to the mental disorders (and pain is one of the most common presenting symptoms of both depressive and anxiety disorders) is just as real to patients as that related to medical disorders.
I consider the major advance in how DSM-IV handled pain in contrast to its predecessors was that it eliminated the DSM-III requirement that psychological factors be judged to be the primary cause of the pain and its DSM-III-R replacement that the patient have preoccupation with the pain. DSM-IV acknowledged that in many cases of chronic and acute pain both psychological and physical factors played roles in the pain and didn't require those making the diagnosis of Pain Disorder to attempt the often impossible task of determining what was chicken and what was egg.(1)
Unlike Dr. Frances who fears the new diagnosis may be overused, I believe it will be rarely if ever used. Drs. Dimsdale, Sharpe, and Creed note the presence in DSM-IV of the diagnosis of "Undifferentiated Somatoform Disorder."
I don't know what their experience is but I have never used this diagnosis nor can I can recall ever seeing it used by anyone else despite spending much of my time seeing the patient population in whom this diagnosis would be most likely to occur.
By the way, Drs. Dimsdale, Sharp and Creed misstate the key feature of somatoform disorders in DSM-IV. They say it emphasized "medically unexplained symptoms." In fact, what it states is that the common feature of these disorders is "the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder." Unexplained is not synonymous with not fully explained. Unfortunately, the misunderstanding by many that if a diagnosable medical condition was present it excluded the diagnosis of Pain Disorder led them to overlook the DSM-IV diagnosis of "Pain Disorder Associated with Both Psychological Factors and a General Medical Condition."
There are two other problems with DSM-5 that are of concern to me and other physicians who treat patients with pain. The first is that there is no place in DSM-5 to identify under Opioid Use Disorder to a separate iatrogenic disorder. At least in the U.S. prescription opioid abuse has become a major problem. Yet we have made few efforts to differentiate between those who have developed problems after recreational use and those whose abuse developed after they were prescribed opioids for a legitimate pain complaint. I should note that I also raised this issue when DSM-IV was being developed but was told at the time that as there were pain experts who said the latter rarely occurred there was no reason to include a diagnosis for it. Many of us knew then it was a problem and the subsequent 20 years have made it apparent to everyone.
DSM-5 also maintains an anachronism from previous editions of the DSM. As in those all pain in the genitalia is considered to be a mental disorder (Genito-Pelvic Pain/Penetration Disorder)even if there are no psychological issues present. Why this pain should be treated differently from other disorders such as tension-type headache, irritatble bowel syndrome, and fibromyalgia is beyond me.
(1) King SA, Strain JJ. Somatoform pain disorder, in DSM-IV Sourcebook, Vol. 2. Edited by Widiger TA, Frances AJ, Pincus HA, et al. Washington DC, American Psychiatric Association,1996,pp 915-931
Competing interests: No competing interests
Extracts from Somatic Symptom Disorders Work Group 'Disorders Description' document, published May 2011, for the second DSM-5 stakeholder review :
"The presentation of these symptoms may vary across the lifespan. A corroborative historian with a life course perspective may provide important information for both the elderly and for children."
"PFAMC [Psychological Factors Affecting Medical Condition]* can occur across the lifespan. Particularly with young children, corroborative history from parents or school can assist the diagnostic evaluation."
"In the elderly somatic symptoms and comorbid medical illnesses are more common, and thus a focus on criteria B becomes more important. In the young child, the 'B criteria' may be principally expressed by the parent."
It appears, then, that the 'B type' Somatic Symptom Disorder (SSD) criteria are intended for application where the parent(s) of a child with chronic somatic symptoms are perceived to be expressing 'excessive thoughts, feelings, and behaviors,' or 'disproportionate and persistent concerns,' or 'maladaptive' coping strategies; or considered to be devoting 'excessive time and energy' to [a child's] symptoms or health concerns or demonstrating 'dysfunctional and maladaptive beliefs' about symptoms or disease.
There is no evidence that SSD or PFAMC have been field tested by APA or by any other group for safety and reliability of application in children and young people.
If the finalized criteria sets and texts for this section allow for the application of a diagnosis of Somatic Symptom Disorder where a parent is considered to be excessively concerned with a child's symptoms, families caring for children with any chronic disease or condition may be placed at risk of wrongful accusation of 'over-involvement' with a child's symptomatology.
Where a parent is perceived as enabling 'maintenance of sick role behaviour' in a child or young person this can provoke a devastating cascade of intervention: placement or threat of placement on the 'at risk register'; social services and child protection investigation; in some cases, court intervention for removal of a sick child out of the home environment and into foster care or for enforced in-patient rehabilitation against the wishes of the family.
This is already happening in the UK, USA and currently in Denmark, in families with a child or young person with chronic illness or disability, notably with Chronic Fatigue Syndrome or ME. It may happen more frequently in families where a diagnosis of chronic childhood illness + SSD has been applied.
This section of DSM-5, seemingly overlooked by clinicians in the field, both within and outside psychiatry and psychosomatics and by medico-legal and disability specialists demands urgent scrutiny and investigation.
*Note: In DSM-IV-TR, PFAMC is located in the Appendix under 'Other Conditions That May Be a Focus of Clinical Attention.' For DSM-5, PFAMC is being relocated to the mental disorders classifications and coded under the new section 'Somatic Symptoms and Related Disorders' that replaces DSM-IV-TR's 'Somatoform Disorders.'
Competing interests: I reviewed and provided comment and suggestions for this BMJ commentary by Allen Frances, MD. I run a website that archives and reports on DSM-5 and ICD-11 activities.
I concur with Professor Frances’ view that the new somatic symptom disorder(SSD)in DSM-5 is vague and risks labelling many people as mentally ill.
There is an evolving understanding of the aetiology of mental disorders over the last decade. Recent advances such as the findings of anti NMDA antibodies in anti NMDA encephalitis (NR1) and NPSLE (NR2A and NR2B), anti thyroid antibodies (Hashimoto’s encephalopathy) and mitochondrial diseases as causes of psychiatric syndromes, take us beyond the traditional paradigm of neurotransmitter dysregulation. One particular characteristic of these disorders is that the presentations span multiple specialties (rheumatolgical, neurological, haematological, psychiatric, gynaecological, endocrine) and have neuropsychiatric involvement as the primary manifestation. These disorders can present with isolated somatic symptoms (e.g. headache, fatigue, neuropathy, loss of movement, movement disorders etc) that fluctuate in presentation requiring the assessing clinician to have a high index of suspicion combined with a thorough exploratory approach to identify the core aetiology.
In clinical practice, the referral pathways to psychiatry make an implicit assumption that organic possibilities have been ruled out by the referring GP or physician. This may lead to medical illnesses being missed unless a through biochemical and medical evaluation is carried out.1 The blood-brain barrier is no longer impenetrable as it was once considered to be, making the mind-body dichotomy an obsolete paradigm. The interface between general medical illnesses and psychiatric disorders is susceptible to two particular biases namely referral bias and spectrum bias which often leads to issues of contention in management.
Patients are referred to the respective specialty based on the presenting distressing complaint. The aetiology of the presenting complaint may, however, not be within the common differential diagnoses of the assessing clinician which leads to a referral bias. For example, a patient complaining of memory dysfunction seeing a psychiatrist may have antiphospholipid syndrome as the primary cause of memory dysfunction which requires a rheumatological/haematological input. Similarly, 75 % of Anti NMDA encephalitis present initially to psychiatrists and are misdiagnosed with a psychiatric disorder.2 It is due to neurological signs or deterioration that a neurological input is sought. Milder cases or incomplete cases (formes frustes) however, may continue to be treated as psychiatric illnesses.2 Thus, the lack of an aetiological approach in psychiatry can miss a modifiable cause.
The other issue in the mind-body interface is a spectrum bias. Evidence suggests that psychiatric disorders can be conceptualised as manifestations of a multisystem disorder.3 Serological investigations may not always detect early manifestations of systemic diseases in psychiatric patients. Thyroid dysfunction and autoimmune diseases such as Systemic Lupus Erythematosus (SLE) are two such examples. The brain has the highest concentration of thyroid receptors than any other organ and is extremely sensitive to changes in the thyroid hormone.4 Furthermore the brain concentrations of T3 and T4 are different from levels found in the periphery.5 Thus, the reliance on the TSH for the diagnosis of thyroid dysfunction in psychiatry may be misleading. TSH has been validated in an endocrine population that may represent a late spectrum of disease and hence may have a poor negative and positive predictive value in a psychiatric population. The ‘great mimic’ SLE presents with multisystem involvement that occurs at any point in the person’s life, requiring the assessing clinician to take a longitudinal perspective in assessment. The criteria for SLE however, represent a late spectrum of disease and do not take into account evidence that the brain may be affected early in the course of the disease even before the other criteria for SLE are met.6,7
According to Mayberg, as our understanding of brain mechanisms mediating complex behaviours continues to grow, the arbitrary operational boundaries separating the clinical disciplines of psychiatry, neurology and immunology become increasingly blurred, requiring new holistic approaches in the study of neuropsychiatric disorders.8 Oyebode and Humphreys recently proposed a paradigm shift in psychiatric training to include training in other specialties like immunology, endocrinology and cardiology.9 The current categorical approach in psychiatry, the validity of which has been questioned, can exclude active consideration and treatment of medical conditions which may be etiologically related. The brain being sensitive to neurotransmitter, neurochemical, neurohormonal and vascular changes may be affected even before the systemic effects on the rest of the body are evident.
Based on my clinical experience, I would propose the adoption of a Multisystem Medical Evaluation (MSME) with the aim of identifying etiological mechanisms in psychiatric evaluation before a diagnosis of SSD is made. Furthermore, a case conference incorporating various specialties should be a prerequisite before this diagnosis is made. The MSME consists of a pan-system history taking and clinical examination based on our existing knowledge of medical aetiology of psychiatric disorders10 to guide investigations and further exploration based on clinical suspicion. This would span a brief immunological, endocrine, vascular, nutritional, structural (trauma, epilepsy) disorder evaluation in addition to the predominant psychiatric evaluation. History taking should guide the clinician to place appropriate weight in the different domains. A brief tailored MSME is useful in routine psychiatric practice as it incorporates a true bio-psycho-social approach. It recognises the important role psychiatrists can play in the detection of physical illness at an early stage.
In summary, the SSD diagnosis is likely to cause more harm than good, shifting the balance towards a diagnosis that would lead to mismanagement of patients. It is a step back in time, is not in line with current advances in psychiatry and reminiscent of diagnoses like hysteria. It would be prudent to heed Plato’s age old advice ““The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated."
1.Koranyi E, Potoczny WM. Physical illnesses underlying psychiatric symptoms. Psychotherapy and psychosomatics 1992;58:155-155.
2.Kayser MS, Kohler CG, Dalmau J. Psychiatric manifestations of paraneoplastic disorders. American Journal of Psychiatry 2010;167(9):1039-1050.
3.Leboyer M, Soreca I, Scott J, et al. Can bipolar disorder be viewed as a multi-system inflammatory disease? Journal of Affective Disorders 2012; 141: 1-10.
4.Shahrara S, Drvota V, Sylven C. Organ specific expression of thyroid hormone receptor mRNA and protein in different human tissues. Biol Pharm Bull 1999;22:1027–33.
5.Bauer M, Heinz A, Whybrow PC. Thyroid hormones, serotonin and mood: of synergy and significance in the adult brain. Molecular psychiatry 2002;7(2):140.
6.Wallace DJ, Hahn BH. Dubois' Lupus Erythematosus, 7ed. Lippincott Williams & Wilkins. 2007
7.Petri M, Naqibuddin M, Carson KA, et al. Brain magnetic resonance imaging in newly diagnosed systemic lupus erythematosus. Journal of Rheumatology 2008;35:2348-2354.
8.Mayberg H. Modulating dysfunctional limbic-cortical circuits in depression: towards development of brain-based algorithms for diagnosis and optimised treatment. Br Med Bull 2003;65(1):193-207
9.Oyebode F, Humphreys M. The future of psychiatry. Br J Psychiatry 2011;199(6):439-40.
10.David, A. Lishman's organic psychiatry: a textbook of neuropsychiatry. Wiley-blackwell. 2009
Competing interests: Dr Sanil Rege is a co-founder at Psych Scene, a company providing educational courses and online resources to trainees for the RANZCP exam and organising CPD events for psychiatrists. He is scheduled to present two papers on topics spanning the mind-body interface at the upcoming RANZCP conference.