The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill – is the title of an article by Allen Frances, chair of the DSM-IV task force, just published in The BMJ.
This is of particular concern to people with CFS and ME since a very popular model for the illness, (originally proposed by Simon Wessely and Trudy Chalder in the early 90’s) is based on the idea that after an initial triggering infection patients are overly anxious about their symptoms, particularly when they increase after exertion, and so they become trapped in a vicious cycle of rest and activity avoidance. Their 1991 paper proposes,”It is plausible that an initial infective trigger may begin a cycle of in which both attributional and cognitive factors fuel avoidant behaviour. The initial symptoms, in particular fatigue and myalgia, engender a state of “learned helplessness”… ” This model now leaves ME and CFS patients vulnerable to being diagnosed as having a psychiatric condition – ‘somatic symptom disorder’!
Belief in this Wessely/Chalder model is now widespread, in spite of the fact that the model did not hold up when tested by the PACE Trail. The response rate for CBT and GET, given in addition to standard medical care, was very low and at least 80% of the patients selected for and completing the trial did not improve significantly. If the model was accurate, most should have improved, recovered and returned to work, or at least stopped receiving disability benefits. None the less, the PACE results were a much better outcome for the researchers model of CFS than the sister MRC funded research, the FINE Trail. This found the treatments were totally ineffective: “At one year after finishing treatment (70 weeks), there were no statistically significant differences in fatigue or physical functioning between patients allocated to pragmatic rehabilitation [a programme of gradually increasing activity using elements of CBT and GET] and those on treatment as usual.” http://www.ncbi.nlm.nih.gov/pubmed/20418251
The International Consensus Criteria for ME states that a cardinal symptom of ME is “a pathological low threshold of fatigability that is characterised by an inability to produce sufficient energy on demand. There are measurable, objective, adverse responses to normal exertion, resulting in exhaustion, extreme weakness, exacerbation of symptoms, and a prolonged recovery period.”
It would seem that any concern patients feel about the restrictions this symptom imposes on their lives can now be assessed as “dysfunctional thoughts, feelings, or behaviours”, making the patient eligible for a psychiatric diagnosis of ‘somatic symptom disorder’ – along with 15% of cancer and heart disease patients and 7% of the healthy population!
The press release for this BMJ article is here http://www.bmj.com/press-releases/2013/03/18/new-disorder-could-classify-millions-people-mentally-ill
Press Release : New disorder could classify millions of people as mentally ill
Monday, March 18, 2013 – 12:54 – New condition that may lead to “inappropriate medical decision making” warns expert.
Personal View: The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill.
Millions of people could be mislabeled as mentally ill when psychiatry’s bible of diagnoses is updated in May, warns a senior doctor in this week’s BMJ.
The next edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – used around the world to classify mental disorders – will include a new category of somatic symptom disorder.
But Allen Frances, Chair of the current (DSM-IV) task force warns that the DSM-5 definition of somatic symptom disorder “may result in inappropriate diagnoses of mental disorder and inappropriate medical decision making.”
The new category will extend the scope of mental disorder classification by eliminating the requirement that somatic symptoms must be “medically unexplained” he explains. In DSM-5, the focus shifts to “excessive” responses to distressing, chronic, somatic symptoms with associated “dysfunctional thoughts, feelings, or behaviours.”
His concern is supported by the results of the DSM-5 field trial study. Somatic symptom disorder captured 15% of patients with cancer or heart disease and 26% with irritable bowel syndrome or fibromyalgia, and had a very high false-positive rate of 7% among health people in the general population.
He points out that, previous DSM criteria “have always included reminders to clinicians to rule out other explanations before concluding that any mental disorder is present. But his suggestions to the DSM-5 work group that similar reminders should be included this time were rejected.
Every diagnostic decision is a delicate balancing act between definitions that will result in too much versus too little diagnosis – the DSM-5 work group “chose a remarkably sensitive definition that is also remarkably non-specific,” warns Frances.
This, he argues “reflected a consistent bias throughout DSM-5 to expand the boundaries of psychiatric diagnosis with what I believe was insufficient attention to the risks of the ensuing false positive mislabeling.”
“The DSM-5 diagnosis of somatic symptom disorder is based on subjective and difficult to measure cognitions that will enable a “bolt-on” diagnosis of mental disorder to be applied to all medical conditions, irrespective of cause,” he adds.
“Clinicians are best advised to ignore this new category. When a psychiatric diagnosis is needed for someone who is overly worried about medical problems the more benign and accurate diagnosis is adjustment disorder.”
Contact:
Allen Frances, Chair of the DSM-IV task force, Coronado, CA, USA
allenfrances@vzw.blackberry.net