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

BMJ 2013; 346 doi: (Published 19 March 2013) Cite this as: BMJ 2013;346:f1580

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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

20 March 2013
Joel E. Dimsdale
Professor of Psychiatry Emeritus
Michael Sharpe, M.D., Oxford, Francis Creed, M.D., Manchester
University of California San Diego
9500 Gilman Dr, San Diego, CA 92093