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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

Somatic Symptom Disorder certainly seems to be of a piece with the concern that official psychiatry will stick a diagnostic label on anything that crosses its path and appears in any way deviant. In the case of this diagnosis and Dr. Dimsdale’s defense, I have two questions regarding his argument and another regarding decisions of the DSM-5 Task Force.

Dr. Dimsdale argues that the new disorder will provide a corrective for the patient-unfriendly DSM-IV notion of “medically unexplained symptoms.” Patients will now feel relieved that their symptoms are not being treated as “inauthentic.” There are two problems with this argument in defense of SSD. First, how is a clinician, medical or psychiatric, going to decide that a seriously medically ill patient’s distress is beyond the bounds of what is appropriate for that patient and that illness. That would only be remotely possible if one began with a stereotyped notion that illness x warrants y amount of distress, with no regard for individual responses to medical illnesses. Second, Dr. Dimsdale’s argument that patients will feel invalidated by “medically unexplained symptoms” applies equally to SSD, where the patient is left to feel, not only do I have a serious medical illness, I now have a psychiatric illness to boot, and just because I expressed my distress. Dr. Frances makes a valid point that SSD represents an expansion of the diagnostic imperium, and judging from some of the responses to his piece, the medically ill public agree.

My other question has to do with decisions of the DSM-5 Task Force. In the Guidelines for Making Changes in DSM-51, SSD, as a new diagnosis, would qualify as a “major change,” and “…the empirical evidence for any change introduced in DSM-V should be proportional to the magnitude of the change. That is, the larger and more significant the change, the stronger should be the required level of support.” The authors of the Guidelines thus say that SSD should require a very high level of empirical support. It’s not evident where and what such support is for SSD. Again, the Guidelines provide a list of ten validators for supporting a diagnosis, and none seem to be strong supports for SSD. In not following its own Guidelines, the DSM-5 Task Force does seem vulnerable to the criticism of diagnostic expansion.

References

1. Kendler K, Kupfer D, Narrow W, Phillips K, Fawcett J. 2009. Guidelines for Making Changes to DSM-V. http://www.dsm5.org/ProgressReports/Documents/Guidelines-for-Making-Chan...

Competing interests: No competing interests

25 March 2013
James Phillips
psychiatrist
Department of Psychiatry, Yale School of Medicine
88 Noble Avenue, Milford, CT 06460, USA