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

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1580 (Published 19 March 2013) Cite this as: BMJ 2013;346:f1580

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

I am writing as a sociology lecturer and researcher, who as part of her research has been critically evaluating psychogenic explanations somatic (physical) illnesses of uncertain aetiology, and as a parent and carer of a woman who suffers from an organic illness that still is subject to uncertainties in knowledge of aetiology. I am author of the book 'Authors of our own Misfortune? The Problems with Psychogenic Explanations for Physical Illnesses'. (Kennedy, 2012)

I submitted a stakeholder response regarding the revision of the American Psychiatric Association’s (APA)’s Diagnostic and Statistical Manual for Mental Disorders (DSM-5), specifically related to the diagnoses that denote psychogenic explanations for somatic (physical) illnesses of uncertain aetiology, and their proposed reshuffling.

Psychiatry, and medicine generally, has historically been dogged by the fundamental problem (indeed, fallacy) of inserting a ‘god of the gaps’ theory into areas where medical knowledge about somatic processes is limited. This sadly has not changed just because medical knowledge has increased, especially as, any reasonable person would acknowledge, medical knowledge is not yet complete, and may never be: therefore gaps in knowledge remain, and unfortunately these are often filled, discursively, with psychogenic explanations.

The new category Somatic Symptom Disorder (SSD), but, crucially, also the diagnosis it replaces, result from a fallacy of assuming that, just because presenting somatic illnesses are not easily explained by immediately obvious organic processes, they are therefore ‘medically unexplained‘, and, by default, ‘psychogenic’ in nature. It denotes a fallacious belief in the doctor that an illness is not organic, but resulting from metaphysical processes based on abstract constructs (beliefs, lies, delusions). These metaphysical processes are conflated with confused beliefs that the patient is doing one or more of the following: malingering; imagining impairment that is not present; hypochondria (having abnormal or inappropriate chronic anxiety about one’s health); or an assumption of “mind over body”processes, denoting a belief that behavioural problems, negative attitudes or emotional tension cause the body to develop impairments, accompanied by a belief that one can think oneself better, actually reduce or eliminate physiological impairment, by the positive power of the mind.

Therefore, far from overcoming the problems of the concept and term of ‘medically unexplained’ illness, which were claimed as an advantage of the new diagnostic categories in the various editorials in psychological, psychiatric and medical journals, the new diagnosis merely reifies and re-jiggles the fallacious notions upon which the category 'medically unexplained illness' was (and is) based.

As a result, this new diagnostic category will lead to greater misdiagnosis (even than is already unfortunately occurring) of organic illness as psychogenic, leading to psychogenic dismissal of illness symptoms and signs, both in patients given diagnoses denoting illnesses of uncertain aetiology (such as, for example, but not limited to, Myalgic Encephalomyelitis or Chronic Fatigue Syndrome, or Fibromyalgia), and in patients with established ‘uncontested’ illnesses, such as cancer, AIDS and diabetes. It will lead to further psychogenic dismissal of somatic signs and symptoms, and an epistemic ‘laziness’ that will prevent doctors from working to elucidate and treat organic dysfunction that may be extremely disabling to a patient, placing that patient at risk of further harm or even death. It will also lead to increased stigmatising and other adverse effects of being assigned a psychiatric diagnosis, in this case based on a fallacy of reasoning. Viewing a patient through the prism of a belief they are psychogenically, not organically ill, leads to doctors and other mistaking a patient’s distress and other responses to the impact of organic illness (especially if difficult to diagnose) as causative of that illness, and indeed, all future illnesses that patient endures.

There is copious evidence that the whole concept of ‘somatoform disorders’ and their synonyms, signifying psychogenic explanations for illnesses of uncertain aetiology, have already led to these problems. The category of SSD therefore will merely reify problematic and often dangerous medical practices that already exist.

Both SSD, and those diagnostic categories it supposedly replaces, signify the problem as described by Thomas Szasz (1997:23):

"In the days of the Malleus, if the physician could find no evidence of natural illness, he was expected to find evidence of witchcraft: today, if he cannot diagnose organic illness, he is expected to diagnose mental illness."

They may indeed fill “the discursive space left inadequately explained by medical accounts”(Newton, 1999: 244). But their usefulness in the filling of ‘discursive space’ of medicine, they are based on fallacious reasoning and cause iatrogenic effects.

While it is to be hoped that, in time, advances in psychiatric and medical reasoning will eventually render the current DSM categories, associated with default psychogenic explanations for illnesses of uncertain aetiology, defunct, the insertion of SSD into the new DSM is extremely worrying because those who propose this new diagnosis clearly believe their proposition already denotes advances in psychiatric thinking, when they do not. It therefore means erroneous confidence in its use may well be high. The insertion is also likely to facilitate an even greater risk of irrational ‘black-boxing’ of alleged but un-elucidated and therefore unsafely assumed ‘psychogenic’ processes, so that doctors will not be required to robustly defend the logic or rationality of their diagnosis, even to themselves, increasing the risk of misdiagnosis and its adverse effects.

REFERENCES

Kennedy, A. Authors of our own Misfortune? The Problems with Psychogenic Explanations for Physical Illnesses (2012) The Village Digital Press, Market Rasen.

Newton, T. ‘Stress Discourse and Individualization” in Feltham (1999) 241-251.

Stone, J. et al ‘Functional Symptoms in Neurology: Diagnosis and Management’ Advances in Clinical Neuroscience and Rehabilitation vol. 4 no. 6 (2005) pp 8-11.

Szasz, T. The Manufacture of Madness: a Comparative Study of the Inquisition and the Mental Health Movement (1997) Syracuse University Press, New York.

Competing interests: Given in response.

21 March 2013
Angela P. Kennedy
University Lecturer
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Buckhurst Hill, Essex