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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

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

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

28 March 2013
Steven A. King
Chair, DSM-IV and DSM-IV-TR Pain Disorders Committees
Pain Management and Psychiatry
New York, NY