The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally illBMJ 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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Twenty years ago, Dr. Frances chaired the DSM taskforce, which emphasized “medically unexplained symptoms” as the key feature of somatoform disorders. Where has that got us?
Patients feel that their complaints are viewed as inauthentic, and doctors can’t agree about what is or is not medically unexplained. All of this reinforces a mind-body dualism, which is more consonant with the 17th century than the 21st . Psychiatric symptoms and general medical symptoms can and do coexist. We think and feel with our brains and are affected by life experience and the cellular milieu that we live in.
The DSM 5 diagnosis of somatic symptom disorder represents an attempt to correct these problems in DSM IV. The DSM 5 diagnosis does not question the reality of patients’ suffering and emphasizes instead that psychiatric disorders are more properly diagnosed on the basis of features such as disproportionate and excessive thoughts, feelings, and behaviors, rather than by negative features like “medically unexplained symptoms.”
Frances complains that the DSM 5criteria will be “too loose.” It is worth pointing out that the DSM IV criteria for “Undifferentiated Somatoform Disorder” yielded higher estimates of the population at risk than do the criteria for DSM 5.
His final suggestion is that physicians should use a “benign diagnosis.” We agree that the DSM IV diagnoses were highly stigmatizing. We hope that the DSM 5 approach will be less so, particularly with the de-emphasis of medically unexplained symptoms. DSM is hardly “a Bible.” DSM IV wasn’t, and DSM 5 won’t be either. The goal of the DSM is to accurately describe the patient’s presentation with the intention of providing helpful treatment. When a patient is better described by one diagnosis than another, it is sensible to use the one that is more accurate.
The one thing we do agree with Dr. Frances on is the importance of caring for our patients. It is debilitating for individuals suffering from multiple persistent somatic symptoms and distressing preoccupations. The diagnosis of Somatic Symptom Disorder may be a logical next step in recognition and treatment of these patients.
Competing interests: The authors are members of the DSM somatic symptoms workgroup
As a 17-year volunteer (medical layman) advocate, writer, and online research analyst for chronic face pain patients, I have interacted with over 4,000 people in pain. From this background, I hope I will be pardoned for speaking truth to power. I find the rationale and concerns offered by Dr Allen Francis to be compelling. I cannot similarly credit the apologia offered by Joel Dimsdale.
Patients widely understand as Dr Dimsdale apparently does not, that many who are referred by medical doctors to a mental health professional are being told either explicitly or by implication that their pain problem is "all in their head". And they roundly reject that inappropriate conclusion.
Some chronic pain patients might be helped by referral to mental health professionals for ancillary support in a program of ongoing medical care. But hundreds of patients tell me that this is not what actually happens. Dealing with complex and time consuming medical issues, patients are referred by over-worked or ill-trained primary care doctors to get them out of the doctor's practice. By any other name, the objective is triage, not patient welfare.
Somebody tell me how a patient's concerns for their own symptoms can ever be judged "disproportionate" when they experience a red hot ice pick being driven through their cheek or into their ear -- repeatedly for hours on end! But this is precisely the judgment applied in terms such as "catastrophic ideation" or "somatic disorder".
If it were up to chronic pain patients, any professional who uses terminology like "psychogenic pain" or "conversion disorder" would have his or her mouth washed out with soap! Patients get it and it's time for doctors to rethink: chronic pain is often co-morbid with depression and anxiety. But correlation is not cause. Depression does NOT cause pain.
Richard A. Lawhern, Ph.D.
Competing interests: No competing interests