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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

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

It is interesting that the concepts underpinning the proposed diagnosis of "somatic symptom disorder" have caused such furore, heightened emotions and confusion, as is evident in the responses.

When I first saw this term, I was completely underwhelmed. On the face of it this seems to me a very bland and soulless term, telling us little about what causes the problem, what the patient experience is and what would be the correct treatment. It does not even have the first name or second name of the person that described it, there is no judgemental tone (cf "conversion syndromes)- it can in many ways be seen to epitomise the failure of diagnostic systems in "conditions of uncertain aetiology".

Is this a "take over bid" by psychiatry so that all known conditions will have a psychiatric sub-classification? I hope not, believe me as a practising psychiatrist I have more than enough clinical work without an exponential expansion of our remit. Is this a long overdue attempt to make sense of a very confused and murky area in the hinterland between "medicine" and "psychiatry"? If so, I like many other remain just as confused and in awe of the amount of work still be done in understanding these significant health problems. I am not sure about the subtext regarding the pharmaceutical industry and their role in
promoting new diagnoses and their treatment. I suspect not, the new term is just not catchy enough or marketable in my view.

I feel that the core issue is that probably neither "psychiatry" or "physical medicine" have perfect diagnostic systems. Sometimes the proposed physical markers of a medical condition turn out to be wrong, there are too many exceptions, or new research challenges the fundamentals of diagnosis. Psychiatry has to rely on narrative, clinical skills of the assessing clinician in the absence of physical markers. Both psychiatric and physical disorders are real, with real suffering affecting real people.

Reading the responses, I was struck by the very real fear that people have expressed of inapproriate labelling, I think this goes beyond "perceived stigma" of having such a diagnosis. My hunch is that this is more related to the understandable worry that treatment is not available, or that inappropriate and ineffective treatment might be offered.

Finally, when looking at the debate and correspondence, I was struck by the analogy of a well-known TV series, where the mobile chemist is trying to refine his wares by using a scientific method to produce high quality drugs. The drugs offer the promise of greater purity, efficacy and reliability. However, they are still dangerous in the wrong hands, have the same problems and are associated with a rather dodgy distribution scene.

I would like to offer the possible aphorism which helps guide me through practice when facing diagnostic uncertainty. "Sceptical about diagnoses, but never about patients".

Competing interests: The views expressed are mine alone and do not necessarily represent those of my employers.

21 April 2013
Sean P J Lynch
Consultant Psychiatrist and Honorary Associate Professor
Devon Partnership NHS Trust and University of Exeter Medical School
Wonford House Hospital, Dryden Road, Exeter EX2 5AF