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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 have worked as a clinical psychologist for over 30 years and as a specialist within NHS cancer care for over 20 years. I object to the new SSD diagnosis on so many levels that it is hard to know where to begin. For starters, once something has a label it begins to be thought of as a real ‘thing’, as if it exists in nature like a bacterial disease or a broken bone. Unlike cancer, however, SSD does not exist in nature; it is a social construction which depends entirely upon a subjective judgment. This would not matter if psychiatric diagnoses did not stigmatise and do damage. Too often I have met people who believe their cancer was diagnosed late because their physical symptoms had been dismissed as “all in the mind”, probably because somewhere in their medical notes they were once given the diagnosis of depression or anxiety disorder. A diagnosis of mental illness sticks to medical notes like glue and influences the perceptions of all who subsequently read them.

Dimsdale, Sharpe and Creed in their response to Frances (Rapid Response, 20th March) say that “the goal of the DSM is to accurately describe the patient’s presentation with the intention of providing helpful treatment.” These are noble sentiments, and in no way would I question the integrity or humanity of the authors’ intentions, but the idea that a three-word diagnosis can accurately describe human experience seems naive at best. All human distress occurs within the context of complicated factors (biological, psychological, emotional, interpersonal, social etc) and it is this context that demands our assessment and understanding, not reducing it all to a subjective judgment by a clinician as to whether a particular emotion is ‘excessive’ or ‘disproportionate’. How much distress ought a cancer patient to have? What democratic authority gives any of us the right to say what is excessive or proportionate about another person’s thoughts, emotions and behaviour? The SSD criteria in this regard are dangerously loose and over-inclusive.

My patients are already often worried that if other people see their physical and emotional distress they risk being perceived as negative, not coping, being ‘weak’, or risk escalating the distress of others around them for which they already feel guilty. It seems likely that this reticence to voice their concerns and obtain support will be compounded if we burden them with yet another medical diagnosis to worry about, one that seems to corroborate their self-doubt. There is already good evidence that cancer patients do not tell professionals about their very real concerns (e.g. pain, Ward et al, 1993), and there is a danger that the fear of a psychiatric diagnosis will amplify this.

People with cancer experience intense levels of fear, often for prolonged periods. When they have finished active treatment it is very common for people to become vigilant about their bodies, looking for signs of disease recurrence, sometimes for years. Do we really need to assign a mental disorder to this very natural state of vigilance? Can we not support people with these concerns without describing their distress in terms of a psychiatric illness?

In light of the epidemic of psychiatric diagnoses over the past two decades (e.g. depression, Horwitz and Wakefield, 2007) one might have thought that psychiatry would be more cautious before constructing new diagnoses. Or perhaps not. With each successive edition of DSM more and more human distress has been colonised as a mental disorder (with this new edition even grief becomes prey). Surely the controversy surrounding the pathologization of human distress and other aspects of DSM-5 should no longer be confined to professional discourse but warrants a more public debate?

References

Horwitz A, Wakefield J. (2007) The Loss of Sadness: How psychiatry transformed normal sadness into depressive disorder. New York: Oxford University Press

Ward SE, Goldberg N, Miller-McCauley V, Mueller C, Nolan A, Pawlik-Plank D, Robbins A, Stormoen D, Weissman DE. (1993) Patient-related barriers to management of cancer pain. Pain, 52, 319-324

Competing interests: No competing interests

25 March 2013
James H. Brennan
Clinical Psychologist
NHS/University
Bristol, UK